health promotion midwifery essay

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Public Health in Midwifery: Reflection Essay Guide

Identify and discuss the importance of learning outcomes from the module in relation to public health. Highlight its significance in midwifery practice.

Introduction: 250words approx • Identify and discuss the importance of relevant learning outcomes from the module in relation to the public health/health promotion that you wish to address and why this is significant in midwifery practice. • Explore and evaluate the value of reflection in developing your midwifery knowledge and practice • Highlight what you intend to discuss in the assignment and why (you can come back to this at the end but if you plan your work, you should identify this at the beginning). Ensure that your chosen reflective model is identified and justified (Discuss rationale with supporting evidence especially why one model was chosen over another). • All sections should include relevant references from credible academic sources (please review the reading list and library database).

  Hire A Writer - Plagiarism-Free Essay Writing Service Body - 3500 words approx. (this will be for the whole reflective cycle you have chosen) Regardless of the chosen reflective framework, please ensure you discuss the following within the chosen framework: • Briefly summarise the topic for the poster and the group dynamics (which will enable you to discuss your own professional development later in the assignment for example – the impact of team work on content, development of poster, workload, communication, challenges. • Identify your feelings at the time and why you felt that way for example – inadequacy as you missed some session or enjoyment of the task and why(therefore, in your analysis you can pick this up to explore the necessity for preparedness). • What you learned from the experience – Evaluate the experience for example – thinking back on your ability to share information with your peers with regards to the public health/health promotion chosen topic. what worked well but what could have been improved – • You should evaluate the influence of psychological, social, cultural, political and economic factors on the woman and her family. • This section should include relevant references and reference to theory. • Analysis - you should already have identified areas for further discussion from what you have reflected on so far. • Relate your points to public health/health promotion theory (not to the poster and group work). • Communicating effectively with women and families and why this is important as part of public health/health promotion strategy • Demonstrate an understanding of the importance of good multi-agency working as part of public health/health promotion strategy • Demonstrate an understanding of the impact of your chosen health promotion model that underpins your chosen topic in relation to public health/health promotion. • This should be supported with current, academic, relevant literature. This section should conclude with a discussion on how this activity has impacted on your learning for future practice and what you will do going forward (Be specific – this relates to a conclusion and action plan).

   Hire A Writer - Plagiarism-Free Essay Writing Service Conclusion: 250 words approx. Please ensure you bring all the points of your reflective account together- relating it to the module learning outcomes and your development as a result. You can include key references already cited from the body in your conclusion but keep this to a minimum. No new material should be introduced in your conclusion. Include a reference list starting on a new page.

Understanding the Importance of Reflection Reflection isn't just about looking back; it's about learning, growing, and evolving. In the realm of midwifery, it enables professionals to identify crucial learning outcomes from modules related to public health. By exploring and evaluating the value of reflection, midwives can enhance both their knowledge and practice, aligning more closely with best practices in public health. The Pillars of Reflective Practice Identifying Feelings and Emotions:   Reflecting on one's feelings during specific scenarios—be it the joy of successful teamwork or the stress of missed sessions—provides a starting point. It allows midwives... Read more

Read Sample Paper Introduction Public health promotion is critical in midwifery practice (Soucy et al., 2023). It ensures that mothers and newborns receive best clinical outcomes (Smith et al., 2017). As such, midwives must understand the principles and practices of public health promotion. This knowledge enables midwives to work with mothers, families, and communities to improve their health and well-being (De Leo et al., 2019; McLellan et al., 2019). This reflection focuses on my experience of developing a health promotion poster for Sudden Infant Death Syndrome (SIDS) using the Gibbs reflective model. It will explore the importance of effective communication and collaboration. It also outlines the significance of using health promotion models in promoting midwifery practice. Additionally, it evaluates the influence of psychological, social, cultural, political, and economic factors on women and their families. Reflection is an essential component of professional development in midwifery practice (Koshy et al., 2017). It enables midwives to examine their practice, identify areas for improvement, and take action to enhance their skills and knowledge (Sweet et al., 2019). Reflective practice also provides midwives with an opportunity to learn from their experiences (Sweet et al., 2019). It integrates new knowledge and skills into their practice and improves the quality of care they provide (Sweet et al., 2019). I have selected Gibbs’ reflective model for this evaluation.  It consists of six stages, which are description, feelings, evaluation, analysis, conclusion, and action plan (Gibbs, 1988). This model provides a... Read More

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Health promotion in pregnancy: the role of the midwife

Affiliation.

• 1 North Tyneside General Hospital, Rake Lane, North Shields NE29 8NH, England.
• PMID: 16220735
• DOI: 10.1177/146642400512500513

Health promotion is of particular importance to midwives who promote health rather than manage disease and ill health. Although the midwife has always had a role in public health, there is now an explicit need for the profession to direct its attention to teenage pregnancy, smoking cessation, drug awareness and domestic violence. Much of the role of the midwife during pregnancy is in health promotion and a more explicit application of such may carry benefits in meeting Government policy on public health. Some activities undertaken by midwives may not be identified as health promotion, though there is evidence that the interaction generated by routine examinations is of benefit to the mother's health. Midwives should work in partnership with women and families, facilitating decisions about the care that they feel they may require. Social disadvantage may impede participation where formal education was not valued or ethnic background or language impaired access to traditional childbirth education. Tackling this is at the heart of current public health policy around childbirth and child care. Education can take place during any interaction and this gives midwives huge scope to provide an educational experience for women each time they meet. For the pregnant teenager the extended family may need to be included in health promotion activities particularly if breastfeeding targets are to be met. A united health and education policy to inform and educate children and teenagers about the benefits of pre-conceptional care and breastfeeding may be needed. In this way young women come into contact with midwives before they are pregnant, before attitudes to breastfeeding are established and before the concept of pre-conceptional care is lost. Although breastfeeding improves health for women and their infants it can become another burden and expectation which they fail to achieve. Professionals need to be sensitive to the possible negative impact on a woman's health, which could be reduced if the emphasis was moved from individual behaviour change to the inequalities within society. Midwives should seek to respond positively to service changes to achieve the goal of multidisciplinary, non-hierarchical patient-centred services. In facilitating change midwives seek to use their influence to the benefit of the pregnant woman.

Publication types

• Health Promotion*
• Maternal Health Services / standards*
• Nurse Midwives / standards*
• Nurse's Role
• Patient-Centered Care*
• Pregnancy Outcome*

• Research article
• Open access
• Published: 08 November 2012

Public health interventions in midwifery: a systematic review of systematic reviews

• Jenny McNeill 1 ,
• Fiona Lynn 1 &
• Fiona Alderdice 1  

BMC Public Health volume  12 , Article number:  955 ( 2012 ) Cite this article

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Maternity care providers, particularly midwives, have a window of opportunity to influence pregnant women about positive health choices. This aim of this paper is to identify evidence of effective public health interventions from good quality systematic reviews that could be conducted by midwives.

Relevant databases including MEDLINE, Pubmed, EBSCO, CRD, MIDIRS, Web of Science, The Cochrane Library and Econlit were searched to identify systematic reviews in October 2010. Quality assessment of all reviews was conducted.

Thirty-six good quality systematic reviews were identified which reported on effective interventions. The reviews were conducted on a diverse range of interventions across the reproductive continuum and were categorised under: screening; supplementation; support; education; mental health; birthing environment; clinical care in labour and breast feeding. The scope and strength of the review findings are discussed in relation to current practice. A logic model was developed to provide an overarching framework of midwifery public health roles to inform research policy and practice.

Conclusions

This review provides a broad scope of high quality systematic review evidence and definitively highlights the challenge of knowledge transfer from research into practice. The review also identified gaps in knowledge around the impact of core midwifery practice on public health outcomes and the value of this contribution. This review provides evidence for researchers and funders as to the gaps in current knowledge and should be used to inform the strategic direction of the role of midwifery in public health in policy and practice.

Peer Review reports

The reproductive period offers maternity care providers the opportunity to maximise the health and well-being of women and their families potentially impacting on public health outcomes, both short and long term. Although all maternity care providers who engage with pregnant women are presented with such opportunities, it is the midwife that could have the most significant impact from regular contact and building of relationships through continuity of care. There are interventions that could be implemented by midwives, which potentially would have a public health impact but it is important such interventions are evidence based. Recognition of the importance of the relationship between public health and midwifery was highlighted when a general review of midwifery in the UK [ 1 ], named public health as one of five key areas of interest. While the review specifically focused on midwifery in the UK, the importance of preventative public health interventions during pregnancy and the postnatal period has been emphasized on a wider scale. Millennium Development Goal 5 focuses on improving maternal health specifying a secondary target aim to achieve universal access to reproductive health by 2015 [ 2 ]. Antenatal care and adolescent pregnancy are specifically mentioned as key to achieving this target, both of which are acknowledged widely, as areas of interest to public health [ 3 , 4 ]. Other areas of national and international interest, which impact on population health (both women and families), include rising caesarean section rates and other interventions during childbirth [ 5 – 7 ], the importance of positive parenting in the early postnatal period [ 8 ] and perinatal mental health [ 9 ]. Within these areas there is opportunity for evidence based public health interventions to be implemented with a view to potentially improving the long term health of women and families.

Aim of the review

This paper presents an update of a systematic review of systematic reviews conducted in 2009. The aim of the 2009 review was to evaluate the effectiveness of interventions relevant to the public health role of the midwife. The 2009 review was commissioned and conducted within the context of the Midwifery 2020 initiative. The final report of the Midwifery 2020 initiative (Delivering Expectations) and full report of the systematic review of reviews [ 10 ] are available freely online from: http://www.midwifery2020.org . A systematic review of systematic reviews was selected as the methodology, given the breadth of this topic area and the timescale of the project. This paper outlines the review methodology and builds on the original review findings by providing new and updated information about effective high quality public health interventions which could be implemented by midwives or other health care providers for women during pregnancy and the postnatal period who have a similar role, for example, public health nurses, obstetric nurses, labour and delivery nurses or health visitors.

The Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA) guidelines was adhered to when conducting this review [ 11 ]. A systematic search strategy was formulated and definitive search terms used relative to key public health topics within midwifery following consultation with Expert Advisory Group members and Midwifery 2020 Public Health Work Stream members. Seven key areas were identified as relevant to the public health role of the midwife, which included: screening; vulnerable groups; breast feeding; mental health and wellbeing; education and support; childbirth and lifestyle factors. The complete list of search terms is available from McNeill et al. [ 10 ].

Search strategy

Databases searched included: MEDLINE, PubMed, EBSCO (CINAHL/British Nursing Index), MIDIRS Online Database, Web of Science, The Cochrane Library, CRD (NHS EED/DARE/HTA) and EconLit. Eligibility criterion included reviews published from 1999 onwards; English language publications and reviews originating from economically developed countries as indicated by membership of the Organisation for Economic Co-operation and Development (OECD). An additional search was conducted of the National Institute for Health and Clinical Excellence, UK (NICE) website to identify key publications or findings from systematic reviews within guidelines. Reference lists of identified reviews were manually searched for additional relevant reviews. The searches were initially conducted in November 2009 and updated in October 2010. The titles and abstracts were obtained and the decision process for eligibility was conducted by all members of the project team in collaboration (JM, FL & FA). Full text was obtained of all eligible reviews and those whose eligibility could not be discerned from reading the abstract. Eligible systematic reviews also had to publish a clearly identified search strategy or detail the reference databases used.

Data extraction

Data were extracted on: number of papers included in the review; methodological details; midwifery intervention; outcome measures and results. Data were systematically extracted using a data extraction form by individual project team members and verified by one other project team member. The project team subsequently met to discuss and achieve consensus regarding any contentious issues. A parallel process of developing a logic model to act as an overarching framework to inform forward planning was also conducted. Logic models are essentially a conceptual framework, which can be used for evidence‐based decision making and planning [ 12 ]. The model is composed of midwifery inputs and activities, producing a logical pathways to short, medium and long term public health outputs.

Quality assessment and effectiveness of reviews

It is important to consider both the type of evidence included in reviews i.e. was the review restricted to randomised trials only or were other types of studies included and also assess how well the review was conducted methodologically. As such, a two stage process was employed: initially the level of evidence was graded and secondly, the methodological quality was assessed. Recognised frameworks were used to support this process [ 13 , 14 ]. In the hierarchy of evidence, randomised controlled trials are perceived as the gold standard and as the aim of this paper is to present high quality evidence, an evidence grade was given to each review based on the Scottish Intercollegiate Guidelines Network [ 13 ] framework in order to distinguish between different levels of evidence. This framework grades the associated risk of bias based on the level of evidence in a hierarchal manner from a grade of 1++ (meta analysis and RCT evidence) through to 4 (expert opinion), as outlined in Table 1 . The SIGN framework was modified as this review was restricted to systematic reviews and therefore reviews could only be graded as 1++, 1+, 1- or 2++. This paper only presents evidence which was graded 1- or above; any review graded below 1- was not deemed eligible for inclusion. Following selection of the type of evidence, the second stage focused on the methodology of eligible reviews. Clarke [ 15 ] suggests the successful interpretation of results from systematic reviews should consider the methodological conduct of the review. The methodological quality of included reviews was assessed and rated as low, medium or high quality. Appraisal of methodological quality was based on Smith et al. [ 14 ], which contains similar elements to other tools used to assess review quality, for example, the AMSTAR tool [ 16 ]. Reviews were graded as high quality if they included evidence of a search strategy, selection and inclusion criterion, assessment of publication bias and assessment of heterogeneity. Reviews were rated as medium quality if no evidence of assessment of heterogeneity or publication bias was provided and low quality reviews were those which provided evidence of a search strategy only. Effectiveness of interventions was evaluated using a similar approach to van Sluijs et al. [ 17 ]. A differentiation was made between reviews which reported a statistically significant difference (P<0.05), therefore referred to as effective and those which reported no difference in effect between control and intervention group and are referred to as inconclusive or not effective (as appropriate). This paper focuses specifically on interventions which are evidenced by a statistically significant meta analysis or where the intervention is supported by a generally positive trend of results when a meta analysis was not possible. Reviews have been included where a small number of studies reported statistically significant positive effect of the intervention however the wider interpretation of these results is limited. As outlined previously, the aim of the original review was to identify any public health intervention relevant to midwifery. However for the purpose of this paper the focus was to report on public health interventions relating to midwifery that demonstrated a statistically significant effect in favour of the intervention (referred to subsequently as effective interventions for the sake of brevity). Reviews graded 1- or above and of high methodological quality which reported evidence of no effect, are not discussed in this paper. However, they have been summarised in Table 2 [ 18 – 23 ]. In the case of any disagreement regarding grading of evidence, quality appraisal of reviews or effectiveness of the intervention, consensus was reached by discussion between all three authors.

Data synthesis

A narrative review is provided for each of the systematic reviews and in table format the number and date range of papers included, intervention(s), primary outcome or other public health outcomes of interest, results (including key statistical findings e.g. p values or odds ratios) are described and whether the review included a meta analysis or not. It was not expected that a quantitative analyses would be conducted given the diversity of interventions across the broad subject of public health.

In total 214 systematic reviews were eligible of which 91 reported on effective interventions and 117 found no effect or were inconclusive. This paper only reports on high quality reviews with a level of evidence grading above 1-. Of the 91 systematic reviews which reported on effective interventions, 36 were identified which were graded as evidence level 1- or above and rated as high quality. The flow chart in Figure 1 presents the sequential process of identifying reviews eligible for inclusion in this paper. An overview of the key findings in relation to interventions demonstrating a statistically significant effect in favour of the intervention from good quality reviews will be presented in the following sections. A summary of included reviews is provided in Table 3 . The findings in this paper are presented chronologically through the reproductive period: preconceptual; antenatal; intranatal and postnatal. Within each section the reviews on similar broad topics have been further categorised: antenatal (screening; supplementation; support; education; mental health); intranatal (clinical care; environment); postnatal (breast feeding; mental health; education; support). The findings section also presents the logic model which was developed in parallel with the searching and analysis of reviews. Logic models enable the visualisation of how interventions or programmes work and the expected outcomes [ 24 ] and have been used to consider the strategic public health benefit of midwifery practice both in the short and long term [ 25 ].

Identification of effective reviews of high quality *some reviews which were included at the request of funder have been excluded from this paper eg economic reviews (n=6) **non significant, non effective or inconclusive reviews, reviews graded 2++,2+ or 2- and medium or low quality reviews are not discussed in this paper.

Findings -effective interventions

Pre conceptual.

There were no high quality reviews that reported on effective interventions in the pre conceptual period.

The majority of reviews reporting effective interventions were relevant to the antenatal period (n=20). Included reviews have been grouped into screening, supplementation, support, education and mental health.

Reviews (n=4) related to screening reported on interventions relating to ultrasound [ 26 , 27 ], lower genital tract infection screening [ 28 ] and the use of decision making aids [ 29 ]. Bricker et al. [ 26 ] conducted a large Health Technology Assessment review on the clinical and cost effectiveness and women’s views of USS. The review comprised of three systematic reviews on routine ultrasound in early pregnancy, routine ultrasound in late pregnancy and routine Doppler ultrasound in pregnancy which were published in the Cochrane database around the time of Bricker et al. [ 26 ] however, all have since been updated or revised in the Cochrane database, one of which has been included in this paper. The final conclusions of Bricker et al. [ 26 ] indicated that a two stage regimen of USS in pregnancy, one in early pregnancy (booking USS) and a second anomaly USS around 20 weeks, was recommended. Whitworth et al. [ 27 ] reviewed the use of ultrasound for fetal assessment in early pregnancy and concluded that it reduces failure to detect multiple pregnancy (RR 0.07 95% CI 0.03-0.17) and accuracy of gestational dating may reduce the number of inductions of labour for post term gestation (RR 0.59; 95% CI 0.42-0.83). The authors also reported there was no reduction in adverse outcomes or health service use by mothers or infants and long term follow up did not indicate detrimental effect on children’s physical or mental development. The impact of antenatal screening for lower genital tract infection for preventing preterm delivery was reviewed by Sangkomkamhang et al . [ 28 ]. The review included one large RCT (n=4155), which indicated that preterm birth before 37 weeks was significantly lower in a group of women randomised to a screening programme before 20 weeks’ gestation (RR 0.55; 95% CI 0.41-0.75). The review provides evidence to suggest there may be some benefit to introducing a universal screening programme for lower genital tract infection; however the results are based on the findings of one study. O’Connor et al. [ 29 ] conducted a review on the use of decision aids for people facing screening decisions. The meta analysis indicated that the use of decision aids, such as leaflets or DVD’s are better than usual care and resulted in: greater knowledge (MD 15.2 out of 100; 95%CI 11.7 to 18.7), perception of risk (RR 0.6; 95% CI 0.5 to 0.8), lower decisional conflict related to feeling uninformed (MD −8.3 of 100; 95% CI −11.9 to −4.8), lower decisional conflict related to personal values (MD −6.4; 95% CI −10.0 to −2.7), reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5-0.8) and reduced the proportion of people who remained undecided post intervention (RR 0.5; 95% CI 0.3-0.8). Although the results suggest decision aids are effective, the effect size was not consistent across studies and only three of the included studies related directly to antenatal screening.

Supplementation

Eight reviews [ 30 – 37 ] considered supplementation during pregnancy including iron, micronutrients, folic acid, calcium and Long Chain-Poly Unsaturated Fatty Acids (LC-PUFA’s). Two reviews [ 30 , 31 ] focused on folic acid supplementation, both of which concurred that the risk of neural tube defect was significantly reduced with supplementation: Blencowe et al., [ 30 ]; 70% reduction; 95% CI 35-86 and Lumley et al., [ 31 ]; RR 0.28; 95% CI 0.13-0.58. Iron supplementation during pregnancy was reviewed by Pena-Rosas and Viteri [ 32 ] who included 49 trials relating to the prevention of iron deficiency or anaemia at term. The authors concluded that daily iron supplementation was associated with increased haemoglobin before birth (MD 6.00; 95% CI 2.75-9.25) and reduced risk of anaemia at term (RR 0.46; 95% CI 0.29- 0.72) based on meta analyses of high quality trials only. Shah et al. [ 33 ] reviewed multi-micronutrient supplementation on pregnancy outcomes and reported there was a reduction in the risk of low birth weight amongst women given micronutrient supplementation (12 studies, RR 0.81; 95% CI 0.73-0.91) and iron-folic acid supplementation (RR 0.83; 95% CI 0.74-0.93) compared to placebo. The mean birth weight was higher (11 studies; WMD 54g; 95% CI 36-72g) in infants born to mothers who had micronutrient supplementation compared to iron-folic acid supplementation (no difference with placebo).

Calcium supplementation was the focus of three reviews [ 34 – 36 ]. Hofmeyr et al. [ 34 ] reported a reduction in pre-eclampsia (RR 0.68; 95% CI 0.57-0.81) and fewer babies born <2500g (RR 0.83; 95% CI 0.71-0.98). However the benefits seen were from small trials and not observed in the largest trial included. Hofmeyr et al. [ 35 ] reported that with supplementation a reduction in blood pressure (RR 0.7; 95% CI 0.57-0.86), pre-eclampsia (RR 0.48; 95% CI 0.33-0.69) and maternal death/morbidity (RR 0.80; 95% CI 0.65-0.97) was noted and advocated research to investigate calcium supplementation at community level. The most recent review [ 36 ] conducted by several of the same authors as Hofymeyr et al. [ 34 ] on calcium supplementation concluded that there was a reduced risk of increased blood pressure (RR 0.65; 95% CI 0.53-0.81) and preeclampsia (RR 0.45; 95% CI 0.31-0.65). The effect was greatest for high risk women (RR 0.22; 95% CI 0.12-0.42) and women with low baseline calcium (RR 0.36; 95% CI 0.20-0.65). Maternal death or serious morbidity was reduced (RR 0.80; 95% CI 0.65-0.97) although this was mostly in low risk women and women with low calcium and there was no effect on preterm births, stillbirth or death before discharge. Horvath et al. [ 37 ] reviewed the effect of advising high-risk pregnant women to take LC-PUFA supplementation on a number of pregnancy outcomes. The authors found a significantly lower rate of PTD <34 wks (RR 0.39; 95% CI 0.18-0.84) although this result was based on two trials (n=291). There was no effect on duration of pregnancy, PTD <37 wks, infant birth weight or the occurrence of IUGR. Although significant, the authors concluded that there was not enough evidence to recommend routine use of LC-PUFA supplements by high-risk women and that further research involving larger sample sizes was needed.

Three reviews [ 38 – 40 ] considered different types of supportive interventions for women during pregnancy. These ranged from using midwifery models of care to provision of emotional support to reduce the risk of preterm delivery or low birth weight infants. Hatem et al. [ 38 ] reviewed midwife led models of care versus other models of care and concluded that the majority of women should be offered midwifery led care. Women who had midwife led models of care were less likely to experience antenatal hospitalisation (RR 0.90; 95% CI 0.81-0.99), use of regional analgesia (RR 0.81; 95% CI 0.73-0.91), episiotomy (RR 0.82; 95% CI 0.77-0.88) and instrumental delivery (RR 0.86; 95% CI 0.78 to 0.96) and were more likely to experience no intrapartum analgesia/anaesthesia (RR 1.16; 95% CI 1.05-1.29), vaginal delivery (RR 1.04; 95% CI 1.02-1.06), to feel in control during childbirth (RR 1.74; 95% CI 1.32-2.30), attendance at birth by a known midwife (RR 7.84; 95% CI 4.15-14.81) and initiate breastfeeding (RR 1.35; 95% CI 1.03 to 1.76). In addition, women who were randomised to receive midwife-led care were less likely to experience fetal loss before 24 weeks’ gestation (RR 0.79; 95% CI 0.65-0.97). There was no difference between groups for birth by caesarean section (RR 0.96; 95% CI 0.87-1.06) and no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01; 95% CI 0.67-1.53) or fetal/neonatal death overall (RR 0.83; 95% CI 0.70-1.00) and their babies were more likely to have a shorter length of hospital stay (mean difference in days: -2.00; 95% CI −2.15 to −1.85). Hodnett & Fredericks [ 39 ] assessed the value of emotional support to women who were judged, by a health professional, to be at increased risk of preterm delivery or having a low birth weight baby. No significant effect was detected for either outcome, however, women receiving support interventions were significantly less likely to undergo a caesarean section (RR 0.88; 95% CI 0.79-0.98) and were more likely to terminate their pregnancy (RR 2.96; 95% CI 1.42-6.17). There was also a trend towards improvement in maternal psychosocial outcomes although this was not significant. Denis & Kingston [ 40 ] reviewed the effect of telephone support during pregnancy and early postpartum period specifically on smoking, preterm birth, low birth weight, breast feeding and postpartum depression. The authors report a positive effect on breast feeding (3 trials; n=618; RR=1.18; 95% CI 1.05-1.33), low birth weight (3 trials; n=2,027; RR=0.78; 95% CI 0.63-0.97) and postpartum depression at 4 weeks (RR 0.24; 95% CI 0.06-1.00) and 8 weeks (RR 0.30; 95% CI 0.10-0.92), although all were from small numbers of trials and the finding on postpartum depression was from one pilot trial including 42 women.

Educational interventions in the antenatal period were the focus of four systematic reviews [ 41 – 44 ] that considered education about pelvic floor muscle training (PFMT) and promotion of smoking cessation in pregnancy Lumley et al. [ 41 ] reviewed the effect of interventions for promoting smoking cessation and included 72 studies of which 56 were RCT’s. Interventions to encourage cessation of smoking had a significant effect on the number of women smoking; 6 out of every 100 stopped, and a reduction in the number of cigarettes smoked by women was also evident. There was a significant reduction of smoking in late pregnancy (RR 0.94; 95% CI 0.93-0.96), reduction in LBW (RR 0.83; 95% CI 0.73 -0.95), preterm birth (RR 0.86; 95% CI 0.74-0.98) and an increase in mean birth weight (53.91g; 95% CI 10.44g - 95.38g). Naughton et al. , [ 42 ] reviewed the use of self help interventions for smoking and reported greater likelihood of quitting compared to usual care (13.2% v 4.9%; OR 1.83; 95% CI 1.23-2.73). The cost effectiveness of this method was also emphasised, however, further research is necessary to determine the intensity level of the intervention to maximise effectiveness. Hay-Smith et al. [ 43 ] and Lemos et al. [ 44 ] reviewed pelvic floor muscle training and concluded that for primigravida women PFMT was effective. Hay-Smith et al. [ 43 ] reported that women without prior incontinence were less likely to report incontinence in late pregnancy (RR 0.44; 95% CI 0.30-0.65) and up to 6 months postpartum (RR 0.71; 95% CI 0.52-0.97) similar to Lemos et al. [ 44 ] who reported significantly reduced development of urinary incontinence from 6 weeks to 3 months after delivery (OR 0.45; 95% CI 0.3-0.66; 4x RCT; n=675). Pregnant women with persistent incontinence 3 months after delivery and received PMFT were less likely to report urinary incontinence at 12 months post delivery (RR 0.79; 95% CI 0.70-0.90) and less likely to report faecal incontinence at 12 months (RR 0.52; 95%CI 0.31-0.87) [ 43 ].

Mental health

One review by Dennis & Creedy [ 45 ] considered interventions to prevent postnatal depression and all but one involved an intervention from a health professional. The authors reported that preliminary evidence suggests that intensive postnatal nursing home visits with at risk mothers assisted prevention of postpartum depression (RR 0.67; 95%CI 0.51-0.89).

Eligible systematic reviews relevant to the intranatal period yielded the smallest number in comparison to either the antenatal or postnatal periods. Five reviews [ 46 – 50 ] were included in this section and considered either clinical care during labour/delivery or the birthing environment.

Clinical care

Cluett & Burns [ 46 ] reviewed immersion in water for labour or birth (n=11) and reported from a meta analysis of 6 RCT’s. There was evidence to indicate that immersion in water for the first stage of labour significantly reduced the rate of epidural, spinal, paracervical analgesia and anaesthetic analgesia (478/1254 versus 529/1245; OR 0.82; 95% CI 0.70-0.98; p 0.025). However further research is required on other outcomes where there was no difference identified including assisted vaginal deliveries, C/S, perineal trauma, maternal infection, Apgar score < 7 at 5 mins, neonatal unit admissions or neonatal infection rates. Rabe et al. [ 47 ] reviewed delayed umbilical cord clamping and indicated from a meta analysis that there are benefits for both term and preterm infants. A delay of 30–120 seconds of cord clamping reduced the need for transfusions (RR 2.01; 95% CI 1.24-3.27, p=0.0049) and intraventricular haemorrhage (RR 1.74; 95% CI 1.08-2.81, p=0.022) in infants born <37 weeks [ 47 ]. Although the short term benefits are clear, further longitudinal work is needed to clarify the long term benefits.

Environment

The birth setting was the subject of four reviews although all were on different aspects. Hodnett et al. [ 48 ] reviewed the evidence regarding alternative versus conventional institutional settings for birth, which did not include any trials conducted in free standing birth centres. The review reported that for women allocated to the intervention (alternative setting) there was a significant increased likelihood of no analgesia/anaesthesia (RR 1.17; 95% CI 1.01-1.35), spontaneous vaginal delivery (RR 1.04; 95% CI 1.02-1.06), very positive views of care (RR 1.96; 95% CI 1.78-2.15), breastfeeding rates at 6–8 weeks (RR 1.04; 95% CI 1.02-1.06) and decreased episiotomy rate (RR 0.83; 95% CI 0.77-0.90). There was no effect on serious perinatal or maternal morbidity or mortality. Continuous support during childbirth was reviewed by Hodnett et al. [ 49 ]. The intervention involved one to one support during labour and found increased likelihood of shorter labour (WMD −0.43 hours; 95% CI −0.83 to −0.04), spontaneous vaginal delivery (RR 1.07; 95% CI 1.04 to 1.12) and were less likely to have intrapartum analgesia (RR 0.89; 95% CI 0.82- 0.96) or report dissatisfaction with childbirth experience (RR 0.73; 95% CI 0.65- 0.83). The authors only reported on outcomes where at least four trials were included in the meta analysis and highlighted that, generally, continuous intrapartum support was associated with greater benefits when it was not a member of hospital staff, when it began in early labour and in settings where epidural was not routinely available. Hodnett et al. [ 49 ] concluded that continuous support should be the norm rather than the exception for all women and further research is required as to the effectiveness of doula or lay support.

One review considered interventions aimed at reducing caesarean section rates [ 50 ]. Chaillet & Dumont [ 50 ] reported from a meta analysis that regular audit, detailed feedback regarding aspects of caesarean section performance (responsibility for decision making, rates, review of cases in clinical practice and multi faceted strategy approaches, such as development of guidelines, education of health professionals and women about vaginal birth after caesarean section (VBAC) were effective for reducing the caesarean section rate (RR 0.81; 95% CI 0.75-0.87). Details of relative risk for each type of strategy are included in Table 3 .

Eleven reviews [ 51 – 61 ] reporting on effective interventions related to the postnatal period. The reviews ranged across four areas: breast feeding; mental health; education and support.

Breast feeding

Reviews on this topic generally related to either support or promotion of breastfeeding. Britton et al. [ 51 ] reviewed the evidence in relation to support for breastfeeding mothers and key findings indicated that all forms of extra support for any breastfeeding (exclusive or partial) increased the duration of breastfeeding (RR 0.91; 95% CI 0.86-0.96) and the effect was greater for exclusive breastfeeding (RR 0.81; 95% CI 0.74-0.89). These findings were supported by Chung et al. [ 52 ] and Sikorski et al. [ 53 ]. Breastfeeding interventions included in both Britton et al. [ 51 ] and Chung et al. [ 52 ] involved formal or structured breastfeeding education, informal breastfeeding education or breastfeeding support either lay or professional. Chung et al. [ 52 ] from a meta analysis of 34 studies reported that breastfeeding interventions were effective in relation to increasing short term (1-3mths) and long-term (6-8mths) exclusive breastfeeding (RR 1.28; 95% CI 1.11-1.48 and RR 1.44; 95% CI 1.13-1.84) although statistically significant heterogeneity was noted for short term exclusive breast feeding (I 2 =55%; p= 0.006). The authors also highlighted an increased rate (22%) of any (RR 1.22; 95%CI 1.08-1.37) and exclusive (RR 1.65; 95%CI 1.03-2.63) short term breastfeeding with interventions that included a component of lay support. Sikorski et al. [ 53 ] reviewed additional support versus standard care and concluded that additional professional support was more beneficial than standard care for duration of any breastfeeding (RR 0.89, 95% CI 0.81-0.97; 10xRCT; n=19,696) and additional lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66; 95% CI 0.49-0.89; 5xRCT; n=2530). Effect sizes for interventions with an antenatal education element (RR 0.85; 95% CI 0.70-1.04) were not statistically significant, while those with a postnatal element alone were (RR 0.80; 95% CI 0.80-0.96). Four trials using WHO/UNICEF training showed significant benefit in prolonging exclusive breastfeeding (RR 0.70; 95% CI 0.53-0.93), but were highly heterogeneous. The authors highlight the need to assess support in different settings especially with low rates, conduct economic analyses and use qualitative research to explore specific elements of support. Dyson et al. [ 54 ] focused on breastfeeding initiation rates and indicated from a meta analysis of five studies (n=582) that breastfeeding education had a significant effect on increasing initiation rates (RR 1.57, 95% CI 1.15-2.15, p=0.005) compared to standard care in low income groups although substantial statistical heterogeneity was noted (I 2 =53.4%). Early skin to skin contact was reviewed by Moore et al. [ 55 ] who reported statistically significant effects of early skin to skin on breastfeeding at one to four months post birth (OR 1.82, 95% CI 1.08-3.07) and breastfeeding duration (WMD 42.55, 95% CI −1.69 -86.79). In this review, data from more than two trials were only available for a small number of outcomes (8/64). Ahmed & Sands [ 56 ] reviewed breast feeding interventions. While the authors were unable to conduct a meta analysis they found from individual trials, statistically significant results relating to kangaroo care, peer counselling, in home breast milk measurement, and post discharge lactation support for improving breast feeding outcomes.

One review focused on improving maternal mental health and considered postnatal psychological and psychosocial interventions [ 57 ]. Dennis & Hodnett [ 57 ] reported that any psychosocial or psychological intervention compared to usual postpartum care was associated with a reduction in the likelihood of continued depression from their review of nine trials. Examples of psychosocial and psychological interventions reviewed included non-directive counselling, supportive interactions, delivered via telephone, home or clinic visits, or individual or group sessions in the postpartum period by a health professional or lay person, cognitive behavioural therapy and interpersonal psychotherapy.

Education and support

One review considered support for women in relation to weight reduction in the post partum period [ 58 ] focusing on the effect of diet or exercise or both for reducing weight after childbirth. They found that women who took part in a diet (1 trial; n=45; WMD −1.70 kg; 95% CI −2.08 to −1.32; z=8.73; p<0.00001), and women on a diet plus exercise programme (4 trials; n=169; WMD −2.89 kg; 95% CI −4.83 to −0.95; z=2.92; p<=0.00049), lost significantly more weight than women in the usual care. The authors also noted that there was no adverse effect on breastfeeding, although cautioned that further research is necessary to confirm this finding. Three reviews considered extra support for vulnerable groups of women in the form of home visiting or parenting interventions [ 59 – 61 ]. Corcoran & Pillai [ 59 ] reviewed rates in repeat pregnancy following the introduction of hospital-based programmes providing education and counselling to a sample of adolescent mothers. They found that although there was a 50% reduction in the odds of repeat pregnancy compared to comparison-control conditions at 19months (OR 0.474; 95% CI 0.322-0.695), the effect had dissipated by 31 months. All studies were US based and the majority conducted in low income groups (74%) and African Americans (60%). Two reviews focused on parenting interventions [ 60 , 61 ]. Pinquart and Teubert [ 60 ] reported small effects on parenting, parental stress, child abuse, health promoting behaviour, cognitive, social development, motor development, child mental health, parental mental health & couple adjustment from parenting education interventions. Vanderveen et al. [ 61 ] demonstrated an overall positive effect on neurodevelopment from early parental interventions (all involved teaching or enhancing parental skills) lasting up to 36 months. Meta analysis of twelve studies indicated higher cognitive scores at 12 months (WMD 5.57; 95% CI 2.29-8.86; p=0.0009), at 24 months (7 studies; WMD 7.59; 95% CI 5.01-14.31; p=0.0003) and at 36 months (2 studies; WMD 9.66; 95% CI 5.01-14.31; p=0.0001), but not at 5 yrs (3 studies p=0.24). The authors suggest further research is needed to clarify the most effective interventions and the long term effect.

Logic model

The parallel development of the logic model resulted in a summary model (Figure 2 ) provides a framework to visualise interventions across the perinatal period and the potential short, medium and long term impact on the health of women, their families and the community. Logic models display relationships between the core elements (context; inputs; outputs and outcomes) and the basic concept is to read from left to right, following a sequence of reasoning. An example of this is provision of education and information about screening in the antenatal period; an aspect of care where inequalities are known to occur [ 62 ]. The context in this example refers to the cultural, political, social circumstances in which the provision of screening is situated. Reading from left to right on the model indicates that the midwifery public health intervention is next so for example if a midwife provides information about antenatal screening for HIV (input), then uptake of screening may improve and at risk women will be identified earlier (outputs) and the effect will improve maternal and infant health during pregnancy. The medium and longer term outcomes are the resultant reduction in morbidity and or mortality in the local population.

Summary Logic Model.

The focus of this paper is the development of the public health role of the midwife based on effective interventions and highlighting the short, medium and long term effects that these interventions could bring about. Any intervention must be considered within the context in which it is to be delivered as inequalities, resources, culture and vulnerable groups can influence the choice of intervention to best suit the population of women being served. The second column represents the inputs or activities; these are the interventions which are intended to bring about the change in outcomes. In relation to public health and midwifery these are interventions that may impact on public health primarily through education, screening and support. The outputs are the products or the targets of the service delivered and can been seen in the boxes entitled organisation of care under short and medium term outcomes. While the logic model provides a visual outline of midwifery public health roles, using this approach facilitates understanding of how public health programs can be planned and subsequently evaluated. Conducting the data synthesis in tandem with developing the logic model has also highlighted where the gaps in knowledge are and identified areas where midwives could potentially have a much greater role and subsequent impact on public health.

This paper sought to report on systematic reviews providing high quality evidence of effective interventions, in essence the ‘cream of the crop’. Reviews reporting on effective interventions were those which presented a statistically significant meta analysis or where the intervention was supported by a generally positive trend of results when a meta analysis was not possible to ensure the recommendations of the paper are based on strong evidence of good quality. There were a number of reviews included which presented statistically significant positive findings. However, in some cases these were limited by small numbers of participants or small numbers of trials included in the review. As a result of conducting the review and analyzing eligible systematic review evidence, three key areas for future consideration were identified including: recommendation and implementation of effective evidence; gaps in knowledge and developing the role of the midwife in public health which are discussed further in the following sections.

Recommendation and implementation of effective evidence

It is clear from this review of effective interventions, there are areas where evidence has been incorporated into guidelines and thus recommended for implementation into routine practice. However, it has also highlighted many areas where it has not. There has been extensive debate and commentary in the literature about knowledge transfer and translation of knowledge into practice, however, this paper confirms that despite the existence of good quality evidence, the gap remains. From this review, several effective interventions were identified, which are already recommended as routine practice, for example education about folic acid supplementation and pelvic floor muscle training to prevent or reduce the risk of urinary incontinence are advocated by current practice guidelines in the UK [ 63 ] and further afield [ 64 , 65 ]. However, to evaluate fully the extent to which guidelines have been applied it is essential to audit practice in order to provide evidence for knowledge transfer. To encourage implementation of NICE guidelines, audit support tools have been developed by NICE on antenatal care or diabetes in pregnancy for use at local level. Effective interventions were also identified which could easily be implemented by a midwife and could potentially impact on public health, such as education programs for parents of preterm infants and implementation of specific strategies to reduce caesarean section rates. Although there is recognition by health professionals these areas are important, this review provides definitive evidence and examples from systematic reviews, of interventions that are effective. Further consideration needs to be given to how to translate these effective interventions into practice using appropriate channels which are effective to facilitate knowledge transfer. These may include stronger collaborations between clinicians and academics and increasing the exposure students have to systematic reviews in education curricula at undergraduate level. Other effective interventions have been implemented on an ad hoc basis for example additional lay or professional support for breast feeding women and strategies to reduce caesarean section rates, which need to be included specifically in policy and strategy documents to ensure widespread implementation and thus contribute to an evidence based public health agenda to improve the health of women and families. Although this paper has focused on reporting effective interventions it is also important to take cognisance of those interventions that are not effective i.e. those which do not work and sometimes are deeply embedded into practice, for example, routine antenatal CTG for fetal assessment [ 20 ]. It was not possible to discuss reviews that demonstrated no effect within this current paper, however, Table 2 provides summary details of the areas where this was the case.

Gaps in knowledge

The review identified many gaps in systematic review literature relating to core midwifery practice, which potentially could impact on public health population goals. The UK Department of Health, Public Health Strategy [ 66 ] emphasizes the importance of improving maternal health and the subsequent impact on reducing infant mortality and premature births and yet this review identified limited systematic review evidence to support the implementation of midwifery interventions that could impact on perinatal morbidity and mortality. The review also highlighted it was difficult to accurately assess the potential public health impact in terms of effectiveness as some interventions were not well evaluated, evidenced by the large number of inconclusive reviews and reviews demonstrating no effect. The review of reviews identified some interventions that were effective but were limited in terms of methodological quality of included studies, for example, small numbers and design flaws, thus demonstrating the need for robust research and evaluation. One example of this is systematic review evidence in relation to weight management or obesity; a topic of growing concern to maternity care providers and yet the evidence from systematic reviews is limited in terms of quality. The systematic reviews included in the original review generally indicated that additional support related to diet or exercise for women in the postnatal period was effective, however, only one review was of a high quality. Another example of this is the evidence around home visiting for vulnerable groups of women in the postnatal period. While a significant body of research, including longitudinal studies has been published on parenting interventions indicating generally positive effects [ 67 , 68 ] the evidence from this current systematic review of reviews is mixed. Current early years governmental policy in the UK focuses on giving children the best start in life and various interventions have been, or are currently being rolled out, for example, SureStart and the Family Nurse Partnership, however the longer term impact on women and families remains to be seen. Logic models highlight the causal linkage between inputs, outputs and outcomes (24). This is illustrated very clearly in relation to support for parents in the form of parenting interventions (input) which can result in the short term outcome of increasing support for women to improve health and lifestyle; optimize lifestyle and child development beyond the immediate perinatal period (medium term) and in the long term improve family health and wellbeing for this generation and those to come.

Developing the role of the midwife in public health

In order for midwives to utilise their potential in relation to public health it is important not only to consider the interventions that could be implemented but also take cognisance of wider strategies and policy relating to public health. The logic model (Figure 2 ), which was developed as a parallel process to the review, provides an overarching framework that should be used by midwives to visualise their contribution to public health. The model illustrates possible future roles but also facilitates recognition of the current contribution of midwives to improving the health of women and their families as part of their core role. An example of this is how vulnerable women (either social or medical) could be identified in the antenatal period by midwives and a supportive or educational intervention implemented which would result in improved outcomes in the short term i.e. reduced pre term birth or improved birth weight. A medium term outcome of this intervention would focus on optimising lifestyle beyond the perinatal period for example collaborating with health visiting services to provide education and support that would potentially have a longer term outcome of improved family health and well being. The review did not identify any systematic reviews which specifically focused on interventions relating to midwifery public health roles, highlighting a gap in review evidence. Biro [ 69 ] suggests it may be challenging for midwives to think beyond individual women but ultimately necessary in order to meet the challenge of public health to improve population health. Reframing routine midwifery activities in a public health context, identifying midwives as public practitioners and building on existing activities, such as collaboration, organisation of care and interagency working are essential to clearly define the relationship between midwifery and public health. An earlier, wider review on health-led parenting interventions in pregnancy and the first three years of life [ 8 ] suggested that many interventions, particularly in relation to supporting parenting, could be provided as part of routine care and that although the optimal time to start programmes was not clear, there was some consensus that those initiated in the antenatal period were more effective. Development of the public health role of the midwife will also require strategic thinking and support from planners and commissioners of maternity services to ensure that midwives can influence policy and effectively implement public health strategies. This will involve dedicating time and resources to develop local policies, providing training for midwives and building good relationships with other healthcare disciplines to work together.

Limitations

There are a number of methodological challenges in using systematic review evidence which must be taken into account. It is difficult to summarise the evidence from systematic reviews as often there is significant diversity between interventions included in individual reviews or outcome measures used. In addition the results presented may be inconsistent between reviews or inconclusive, however, Smith et al. [ 14 ] suggest the strength of systematic reviews of reviews is that the best quality reviews can be highlighted in a single document. Systematic reviews are generally limited to published work and thus may be subject to publication bias. In addition, more recent, potentially conflicting, research may be available since the review was published or there may be effective interventions that have not been evaluated in a systematic review. A recent Cochrane overview of systematic reviews [ 70 ] highlighted that such reviews provide an accessible summary on the totality of the evidence in the area and minimised the need for referral to individual reviews, however suggested that readers may wish to do so for specific details. This review was similar in that it covered a broad scope of the evidence in relation to public health, providing a strategic overview while also providing a valuable resource for those who wish to consult individual reviews for additional specific details. In this paper, only high quality reviews (based on level of included evidence and methodology of review) reporting on effective interventions were included. While this provides reassurance regarding review findings, in that the conclusions are based on top level evidence, some interventions demonstrating effect may have been excluded because the review itself did not meet either the quality or level of evidence criteria for inclusion. In most cases this relates to areas worthy of future investigation, which need more robust evaluations. The search strategy utilised in the review was specifically focused on the public health role of the midwife and therefore incorporated key terms relative to key areas. However in doing so, some postnatal interventions, which extend beyond the role of the midwife, for example, parenting interventions that continue into early childhood may not have been included. In addition, due to the inclusion and exclusion criteria applied, it is possible that extensive broad reviews on particular topics have been excluded from this review due to the nature of evidence included within them, for example, the NICE Guideline on Antenatal and Postnatal Mental Health [ 9 ]. However, it is recognised these are valuable resources and contribute to wider understanding on specific subjects.

This paper has reported on high quality effective interventions identified from a larger systematic review on public health interventions that could be delivered primarily by midwives or maternity care providers. From the effective interventions identified it is clear that while some have been recommended for implementation into routine practice, others have not. This highlights the continuing gap between evidence and practice and the need for professionals and researchers to work better together to ensure specific interventions that are effective, are translated into practice and subsequently audited to provide evidence of knowledge translation. The public health role of the midwives has not been well researched or reviewed and the impact of everyday midwifery practice on longer term, holistic maternal and family well-being outcomes is poorly articulated in review literature. A shift in research, policy and practice is needed to fully articulate the public health role of the midwife. This systematic review of systematic reviews identifies a number of effective interventions that provide a useful starting point on which to build future practice. The logic model demonstrates the need to fill in major gaps in our knowledge on effective interventions to achieve both short and long term public health benefits for women and their families. Such benefits will remain elusive without investment in a collaborative, strategic approach to the role of public health in midwifery.

Advisory group members

Ms Liz Bannon , Senior Midwife, & Co Director of Maternity Services, Social Services, Family & Child Care Belfast Health and Social Care Trust, Belfast, Northern Ireland; Professor Debra Bick , Professor of Evidence Based Midwifery Practice, Kings College London, England; Dr Helen Cheyne , Nursing, Midwifery & Allied Professions Research Unit, University of Stirling, Scotland; Professor Mike Clarke , then Professor of Clinical Epidemiology & Director of UK Cochrane Centre, now Professor/Director of MRC Methodology Hub, Queen’s University Belfast; Ms Joanne Gluck , Consumer Representative; Professor Billie Hunter , Professor of Midwifery, Swansea University, Wales; Dr Dermot O’Riley , Centre of Excellence for Public Health Northern Ireland, Queen’s University Belfast, Northern Ireland.

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Acknowledgements

We would like to thank all members of the Advisory Group for their contribution and guidance throughout the project. In addition, we would like to thank Midwifery 2020 for funding the original review and in particular, The Public Health Workstream Group who commissioned the original review.

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The original review was funded by NHS Education for Scotland, Midwifery 2020, UK.

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JM extracted and interpreted data and wrote the first draft of the manuscript. FL conducted the searches of the literature, extracted and interpreted data and assisted with the manuscript. FA extracted and interpreted data and assisted with the manuscript. All authors read and approved the final manuscript.

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McNeill, J., Lynn, F. & Alderdice, F. Public health interventions in midwifery: a systematic review of systematic reviews. BMC Public Health 12 , 955 (2012). https://doi.org/10.1186/1471-2458-12-955

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Investigating midwives’ barriers and facilitators to multiple health promotion practice behaviours: a qualitative study using the theoretical domains framework

• Julie M. McLellan   ORCID: orcid.org/0000-0003-4902-2254 1 ,
• Ronan E. O’Carroll 1 ,
• Helen Cheyne 2 &
• Stephan U. Dombrowski 3  

Implementation Science volume  14 , Article number:  64 ( 2019 ) Cite this article

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In addition to their more traditional clinical role, midwives are expected to perform various health promotion practice behaviours (HePPBes) such as informing pregnant women about the benefits of physical activity during pregnancy and asking women about their alcohol consumption. There is evidence to suggest several barriers exist to performing HePPBes. The aim of the study was to investigate the barriers and facilitators midwives perceive to undertaking HePPBes.

The research compromised of two studies.

Study 1: midwives based in a community setting ( N  = 11) took part in semi-structured interviews underpinned by the theoretical domains framework (TDF). Interviews were analysed using a direct content analysis approach to identify important barriers or facilitators to undertaking HePPBes.

Study 2: midwives ( N  = 505) completed an online questionnaire assessing views on their HePPBes including free text responses ( n  = 61) which were coded into TDF domains. Study 2 confirmed and supplemented the barriers and facilitators identified in study 1.

Midwives’ perceived a multitude of barriers and facilitators to carrying out HePPBes. Key barriers were requirements to perform an increasing amount of HePPBes on top of existing clinical work load, midwives’ cognitive resources, the quality of relationships with pregnant women, a lack of continuity of care and difficulty accessing appropriate training. Key facilitators included midwives’ motivation to support pregnant women to address their health. Study 1 highlighted strategies that midwives use to overcome the barriers they face in carrying out their HePPBes.

Conclusions

Despite high levels of motivation to carry out their health promotion practice, midwives perceive numerous barriers to carrying out these tasks in a timely and effective manner. Interventions that support midwives by addressing key barriers and facilitators to help pregnant women address their health behaviours are urgently needed.

Peer Review reports

Contributions to the literature

This research systematically examines barriers and facilitators midwives perceive in helping pregnant women with multiple health behaviour change

The theoretical domains framework is used to understand midwives’ multiple health promotion practice behaviours across a range of health topics

The barriers and facilitators health care professionals face in addressing multiple health behaviour change topics will help inform interventions to support the uptake of evidence-based guidelines into routine clinical healthcare practice

Introduction

In many developed countries, the public health focus for midwives has extended from health protection issues, such as reducing maternal and infant mortality and preventing the spread of disease, to health promotion topics, such as smoking cessation, and weight management [ 1 ]. In the United Kingdom (UK), midwives are expected to perform multiple health promotion practice behaviours (HePPBes) for a variety of health promotion topics throughout pregnancy and postnatally. Examples of HePPBes include monitoring carbon monoxide levels, discussing recommended daily fruit and vegetable intake or delivering an alcohol brief intervention (in the UK, the booking appointment takes place between 8 and 12 weeks gestation and is the first routine antenatal appointment).

HePPBes are outlined in the various policies, strategies and guidelines published by government and public-sector bodies, which either directly or indirectly implicate midwives as public health professionals [ 2 , 3 , 4 ]. For example, in the UK, the National Institute of Clinical Excellence (NICE) Smoking: stopping in pregnancy and after childbirth guidelines outline that midwives participate in up to 12 different smoking cessation-related HePPBes during pregnancy, such as measuring carbon monoxide levels, asking the woman if they or anyone in their household smokes and referring to NHS Stop smoking services [ 4 ]. Whilst the NICE Weight management before, during and after pregnancy guidelines [ 5 ] outline various HePPBes including measuring weight and height, asking questions about the pregnant women’s diet and physical activity and giving dietary and physical activity advice. For pregnant women with a BMI ≥ 30, midwives are expected to carry out additional HePPBes such as offering referral to a dietitian. Considering the variety of health promotion topics to be addressed during pregnancy, midwives face a high health promotion workload [ 6 , 7 , 8 , 9 , 10 ].

The factors related to midwives performing multiple HePPBes are poorly understood. Previous studies have examined maternal health care professionals’ behaviour using the theoretical domains framework [TDF; 11 [ 11 ]]. However, these studies examined single health-risk topic such as smoking cessation [ 12 ], weight management and obesity [ 13 ] and physical activity [ 14 ]. The TDF provides a comprehensive grouping of the overlapping constructs within behavioural theories. The original version (TDF v1) summarises the main factors of relevant behaviour change theories into 12 independent domains [ 11 ]. The TDF v1 has been validated through the development of a refined version (TDF v2; [ 15 ]).

Midwives experience several challenges in undertaking multiple HePPBes such as a shortage of resources [ 6 ], a lack of clarity about their public health role [ 7 , 8 ] and lack of self-efficacy [ 8 , 9 ]. However, limited evidence exists on the barriers and facilitators midwives perceive in undertaking multiple HePPBes. This study applies a theoretical approach to investigate potentially relevant factors at a multiple behaviour level.

Research aim

The aim of this study is to investigate midwives’ barriers and facilitators to performing multiple HePPBes across various health promotion topics using the theoretical domains framework in qualitative interviews (study 1) and free text questionnaire responses (study 2).

This study reports two different sources of qualitative data gathered through interviews and questionnaires. Interviews obtained detailed evidence about the barriers and facilitators midwives experience in carrying out their HePPBes. The questionnaires used an open-ended question to capture additional comments on barriers and facilitators that midwives may have had about their HePPBes.

Study design

Qualitative semi-structured interview study.

Participants

Midwives working in a community setting were eligible to participate if they were qualified, practising midwives employed by an NHS health board in central Scotland. Recruitment involved JM, a researcher previously unknown to participants, visiting an out-patient maternity clinic and providing 12 midwives with information about the study. The information provided to midwives included the reason for carrying out the research to inform JM’s PhD to develop an intervention to support midwives in addressing health behaviours with pregnant women. Eleven midwives agreed to take part. One midwife opted not to take part in the study.

Interview topic guide

The interview topic guide (see Additional file  1 ) contained (i) demographic questions (number of years of experience and job title) and (ii) questions based on each of the 12 TDF (v1) domains [ 11 ]. The behavioural category of interest, within the topic guide, was specified as: “supporting pregnant women to change their health behaviour” and the questions were designed to elicit beliefs about the behaviour in relation to each domain.

To remind midwives of the target behaviour of interest, an A4 prompt card was placed in front of them outlining typical examples of women’s health behaviours to be addressed (see the prompt card in Additional file  2 ). The behaviour was specified using terms Target, Action, Context and Time, known as the TACT principle [ 16 ]. TACT summarises the behaviour in terms of doing what, to whom, in a given context and at a specific time [ 17 ]. The behaviour was specified as: “All the things you do in a routine antenatal care consultation, including asking questions, to support pregnant woman change their health behaviours”. The TACT specification complements the general TDF definition used within the topic guide by breaking down of what was meant by “supporting pregnant women to change their health behaviour”.

Face-to-face semi-structured interviews were conducted by JM (a female PhD researcher and Health Psychologist with previous experience of supporting midwives’ behaviour change practice) on two separate occasions in October 2016. Interviews took place within consultation rooms at an out-patient maternity clinic in central Scotland. Information about the study was provided verbally and in written format. Interviews lasted between 27 and 76 min (mean ± SD, 43 ± 14). All interviews were audio recorded and anonymously transcribed verbatim. The demographic data was entered into a Microsoft Excel spread sheet. The consolidated criteria for reporting qualitative research (COREQ; [ 18 ]) was used to ensure all aspects of the qualitative research had been reported (a copy of the checklist is provided in Additional file  3 ).

Transcripts were stored as Microsoft Word documents. Qualitative data analysis was based on recommendations for conducting TDF based qualitative research [ 19 ] and involved the following ten steps:

Interviews were read several times by JM to ensure familiarity with the data.

One interview was jointly coded by JM and SD to develop a coding strategy.

Two interviews were coded by JM using a directed content analysis approach [ 20 ] in which interview content was placed in the most relevant TDF domain(s). Responses which could be attributed to more than one domain were coded into multiple domains.

The coding of the two interviews was checked by SD. Where discrepancies in coding occurred, discussion took place to reach a consensus.

The remaining interviews were coded by JM.

Data saturation was reached as the final three transcripts did not introduce any additional barriers and facilitators than those already identified.

Summaries of domain codings were produced by JM and checked by SD.

Identification of relevant theoretical domains was identified by consensus discussion between JM & SD. Relevance of a domain was based on the following criteria: (i) high frequency of specific beliefs and/or (ii) existence of conflicting beliefs and/or (iii) indication of clear beliefs that may influence the behaviour of interest [ 21 ].

Views were generated for relevant domains by JM and coded as being either generic (views which are made in reference to HePPBes in general) or behaviour specific (views which are in reference to a specific health promotion behaviour).

The views generated were checked by HC (a Professor of Midwifery) to ensure they made sense from a midwifery perspective.

Ethical approval

The University of Stirling Psychology Ethics Committee approved the study. NHS Research and Development approval was granted by Greater Glasgow and Clyde Health Board (R&D reference: GN16OG406).

Online questionnaire study including a qualitative open-ended question.

Individuals registered as a qualified midwife or training to be a midwife, worldwide, were eligible to take part. Recruitment took place online between the February and May 2018. Advertisements were placed on discussion forums, email lists and social media pages. The study was endorsed by the Royal College of Midwives on their Facebook and Twitter pages. Advertisements contained an URL link to the online study platform Qualtrics where the questionnaire was hosted. Overall, 719 participants consented to take part in the study and confirmed they were either a qualified or student midwife. Of those, 214 completed less than 95% of the questionnaire and therefore were excluded from further analysis. Complete responses were obtained from 505 participants.

Questionnaire

The questionnaire examined factors relevant to HePPBes. At the end of the questionnaire, participants were asked: “If you have any other comments on your Public Health role then please include them below”. The current paper reports on the qualitative data obtained from this question.

Midwives accessed the questionnaire by clicking on the URL contained within the online advertisement. Following presentation of study information and eligibility criteria, consent was obtained by the midwife selecting an electronic check box. A screening question: “Are you a qualified or student midwife?” was presented as a method of reducing the likelihood of non-midwives completing the questionnaire. If the response was “no”, then participants were thanked for their interest in the study and exited from the questionnaire. At the end of the questionnaire, midwives were offered the opportunity to be entered into a prize draw to win 1 of 4x £25 shopping vouchers.

Analysis of the qualitative questionnaire data involved the following five steps:

Responses were read several times by JM to ensure familiarity with the data.

Responses were coded by JM using a directed content analysis approach [ 20 ] in which responses were placed in the most relevant TDF domain. If a response could be coded into more than one domain, a decision was made by JM as to the most appropriate domain.

Coding was checked by SD.

The number of responses coded into each domain was calculated by JM.

JM checked how much the barriers identified reflected those in study 1 and if there were any additional barriers or facilitators identified.

The University of Stirling’s General University Ethics Panel approved the study (GUEP316).

All 11 participants were female, employed as community midwives, except one who worked as a Senior Charge Midwife. The mean number of years of experience as a qualified midwife was 22 (range from 3 to 31).

Reviewing of coding

Agreement between coders for two interviews was 76% and 88% for the first and second interview respectively, and disagreement for the same interviews was 17% and 5% respectively. The mean agreement was 82% and mean disagreement was 11%. An additional 7% of codes were suggested by the second coder for each interview.

Relevant theoretical domains

All barriers and facilitators could be identified within the TDF. Nine of the 12 TDF domains were classified as important in understanding the barriers ( b  = barrier) and facilitators ( f  = facilitator) to undertaking HePPBes. Table  1 lists these domains alongside a domain descriptor.

The identified domains are outlined below and a table containing the associated belief statements are provided in Additional file  4 .

Professional role and identity

Midwives mostly saw HePPBes as part of their professional role (f): “I just see it as my job” (M10) and “I think public health is an essential part our role” (M7). However, some thought that several HePPBes could be addressed prior to conception, especially around weight management (b): “She’s thirty-five and she’s pregnant, so why is it suddenly the midwife that has to look into that?” (M3). Midwives frequently mentioned that the role of the midwife had evolved from providing traditional midwifery care (e.g. measuring the growth of the baby) to having a strong focus on undertaking HePPBes (b): “They seem to keep adding to the list of things we’re expected to do”(M11), and some midwives expressed a feeling that their traditional professional role was being eroded (b): “Our role now, as community midwives, seems to be for referring on … it feels as if your role’s been kind of eroded at” (M10).

Beliefs about consequences

Midwives mentioned several consequences that potentially impact their HePPBes. Contrasting beliefs about how HePPBes impacted on the relationship with the woman were voiced. If performed well, midwives believed it could be useful in gathering information about aspects of the women’s wellbeing (f). However, some stated that performing HePPBes could potentially damage the relationship if they were not carried out carefully, particularly for HePPBes related to weight management (b): “Women get quite offended at that one” (M10).

Similarly, contrasting beliefs about the womens’ receptiveness to HePPBes emerged. Some midwives reported that women expect them to carry out HePPBes (f): “Most women are quite receptive to that because they know they’re pregnant and know it’s not just about their health anymore” (M11). Other midwives said that women were not receptive to HePPBes (b): “It seems to be that everything is piled on to this booking visit and I don’t think it’s fair on the women either” (M3).

The time it takes to perform HePPBes was seen as a clear barrier with appointments over running the allotted time which could impact on other women (b): “You run over and then people are kept waiting.” (M11). Furthermore, midwives held a clear belief that HePPBes had the potential to have positive health benefits for the women and their child (f): “Absolutely, there’s a huge knock-on effect” (M5). Clear views on the short-term impact of HePPBes depended on the behavioural topic. For instance, smoking was perceived as an issue that could be dealt with during pregnancy (f): “This is probably a time, particularly for the smokers, they’ve got that motivation for the baby to change” (M5). Meanwhile, the impact of diet-related HePPBes was considered as unobservable (b): “I’m never going to know whether she’s changed her diet, or even if she did change her diet, whether that’s going to last” (M6). Some midwives expressed a clear belief that it was rewarding for them to observe the benefits of women engaging in health behaviour change attributed to their HePPBes (f): “That is rewarding if you feel like you’ve helped someone make a change in their life.” (M11). Benefits in reducing future workload if HePPBes were carried out effectively were noted (f): “If we do our job well at the booking clinic and women take that on board then we don’t have as much to do” (M2).

Motivation and goals

Midwives frequently reported being highly motivated to undertaking HePPBes to benefit the long-term health of the woman and the baby (f): “I think it’s a huge window of opportunity for midwives” (M5). However, HePPBes were not a priority if there were conflicting clinical risks to the woman and/or baby such as patient safety or adult/child protection issues (b): “I’d say it’s definitely secondary though, obviously check the woman’s blood pressure, making sure she’s well, doing urine analysis, making sure there’s no infections, ruling out pre-eclampsia, listening to baby. That comes first and everything else, I think, would come second to that.” (M11).

Memory/attention and decision processes

Midwives described being prompted by the woman’s maternity notes to cover all HePPB topics (f): “My booking visit would be just going through that book with them because everything I need to tell them is in there, it’s a good thing for me cause it saves me forgetting to stop to talk about things” (M3) which also acted as a prompt to HePPBes at follow-up appointments (f): “I usually always have a wee flick through the notes at the beginning just to check if there’s any kind of outstanding issues to be aware of (M11)”.

If the woman wanted to discuss a particular behaviour, midwives prioritised this (f): “If the woman is worried about her weight, I’m happy to talk about it at every appointment, but if she’s not then I’m not gonna bring it up”, (M6). Some midwives covered a topic in depth if they felt it was of specific relevance (f): “Say I did three bookings yesterday one of them would have had none of these problems, one of them had a BMI was over 35 so that’s the one I concentrated on.” (M5).

Intuition was frequently reported as guiding decision making in relation to HePPBes (f): “If I get vibes from them, that actually they do know” (M5) and “I just have to go with my gut at the time” (M6) . Midwives also based performing HePPBes on the physical health of the woman during the appointment (b): “If they are very sick or they’ve had bleeding, then I’ll just say, ‘we’ll talk about this another time’ because it’s not appropriate to get ahead of ourselves” (M2).

Environmental context and resources

Changes in health care service provision (e.g. changes in timing of booking appointments) were perceived as making it more difficult to carry out HePPBes (b): “… with continuity of care being removed from us we’re not getting the same chance to see the same women again so I find it a bit harder to address things.” (M10).

Some midwives held a belief that accessibility to resources such as training related to HePPB could be improved (b): “It’s quite haphazard how you can get on to these things” (M4). Materials related to HePPBes were generally perceived as high quality (f): “‘Ready Steady Baby’ is I think a fantastic book” (M10). However, some felt the wording of questions within maternity notes made them difficult to ask (b): “That’s a barrier to me asking, because I actually don’t ask the way it’s worded on that because it doesn’t make sense.” (M4). A belief that there were too many HePPBes to undertake in too little time was apparent (b): “We’ve also got to try and work within the time constraints” (M9). Some midwives believed that the woman’s health status at the booking appointment affected the degree to which they could carry out HePPBes (b): “The booking appointment is really difficult for some women to sit there and actually not vomit” (M7). Physical cues were mentioned as prompts to undertake HePPBes (f): “If you pick up a book and it stinks of smoke, you know, you might well say, how you getting on?” (M2).

Social influences

Women were reported as a strong influence on midwives HePPBes and were seen to increasingly inform themselves through online sources. This was perceived as helpful to recommend high-quality information (f): “Get them to use websites because most of them are on computer all the time anyway” (M3) and unhelpful due to the potential to increase stress (b): “A lot of the women have got health anxieties and that’s fuelled by the internet” (M2). Mixed views emerged about how accurately women reported some health behaviours such as alcohol consumption, which impacted on health promotion efforts. Some midwives perceiving accurate accounts (f): and others reporting the opposite (b): “Alcohol, I think, is probably one that’s probably hidden, getting women to be honest is probably very difficult” (M10).

Team working and social support was seen as helpful in resolving issues regarding HePPBes (f): “My kind of closest colleagues, we’d probably have a wee chat and we’ll probably complain about how we’re meant to put this in amongst everything else that people want out of us.” (M10). Intergroup conflict was perceived by some in relation to performing HePPBes (b): “It’s come up in the tearoom and there will be conversations with people saying, ‘Oh public health that’s a load of nonsense’ and I’ll sit there quite openly and say ‘I think it’s one of the best things that’s ever occurred’” (M7).

Midwives described shifting social and group norms useful to normalise addressing health behaviours (f): “There’s very few people that are not happy to answer these questions nowadays because we’ve been doing this for so long they expect it and they do all talk amongst each other” (M7). However, social norms appeared to be unhelpful in normalising obesity (b) “If a lady’s got a BMI of not over 30, I still sort of don’t see it as a huge issue with them” (M7).

Some saw a midwife’s own body mass index (BMI) potentially making it harder to perform weight management HePPBes (b): “I think midwives find it really difficult because if you’re big yourself they’re looking at you thinking: ‘well, she’s got a cheek’, if you’re small they’re looking at you thinking: ‘you have never had a problem in your life’” (M10).

Carrying out HePPBes was associated with a range of positive emotions if these were seen to result in positive outcomes (f): “You feel dead pleased they actually brought it up again” (M9). Some reported concerns about performing specific HePPBes (b): “I do find it causes me anxiety if I know I’m going to tell her today that we’re doing a Social Work referral.” (M10). Carrying out HePPBes was potentially stressful (b): “Sometimes I’m thinking you just want to do the right thing, which is hard sometimes” (M5) and draining (b): “I’m exhausted after a clinic because you feel as if you want to have your senses hyper alert” (M9).

Behavioural regulation

Midwives described using behavioural regulation strategies such as using maternity notes as a prompt to cover all HePPBes, writing notes in SWHMMR as prompt for carrying out HePPBes follow-up appointments, carrying out HePPBes whilst performing clinical tasks, e.g. asking questions about physical activity while taking bloods (f): “I have to say I multi task. I’ll be testing the urine while I’m asking about how they feel in pregnancy and had they had any sickness and how they’re getting on with eating.” (M7). For a list of strategies reported, see Additional file  5 .

Nature of the behaviours

The majority of HePPBes took place at the booking appointment when there is usually the most time to undertake HePPBes (f). Midwives reported HePPBes as being routine practice (f): “We’ve got to tick boxes, we’ve got to tick that we’ve discussed alcohol, we’ve discussed smoking” (M10). The habitual nature of performing HePPBes included the strategies used to regulate health promotion practice as well as the behaviours themselves.

Study 2 results

Forty-seven fully qualified midwives and 14 student midwives provided a statement to the final question. The majority (92%) were based in the UK. The mean number of years of experience as a qualified midwife was 17 (range from 1 month to 40 years).

Responses were coded into seven TDF domains: professional role and identity, beliefs about consequences, motivation and goals, environmental context and resources, social influences, emotion and beliefs about capabilities. The definitions for each domain are the same as those presented in study 1. The domains are presented in terms of (i) the number of responses and (ii) supporting evidence.

Twenty-six responses were coded as environmental context and resources focusing on a need for improved resources, particularly a need for more time, wider access to online materials: “Apps and online mediums for encouraging behaviour change may take the pressure off midwives” and more accessibility to training . Some responses stressed the need for continuity of care.

Nine responses were coded as beliefs about consequences. The potential for weight management HePPBes to impact the midwife-woman relationship was mentioned. Mixed responses about women’s receptiveness to HePPBes emerged .

Nine motivation and goals responses suggested high levels of motivation to carry out HePPBes . Some midwives indicated that the degree to which they were able to support women was not ideal.

Eight responses were coded as social influences and focused on midwives’ own health status in relation to undertaking HePPBes. Some midwives described their own health behaviours and status helping or hindering HePPBes: “My own lifestyle and motivation in public health topics can impact the delivery and communication when approaching topics with women” . Others reported that their health status was irrelevant: “Don’t confuse my welfare with those of the woman and baby I’m caring for... public health roles should not be judged by the delivering midwife”.

Three responses were coded as professional role and identity commenting on a need for health promotion topics to be tackled before pregnancy and the demands placed on midwives to fulfil multiple professional roles.

Three responses coded as emotion focused on the taxing nature of the job and the potential negative health consequences of burn-out.

Beliefs about capabilities

Three responses coded as beliefs about capabilities highlighted that midwives potentially feel more confident in addressing health promotion topics which have greater attention placed on them in health policy and that capability to undertake HePPBes was reliant on resources such as training and time .

Integration of study 1 and 2 findings

Table  2 presents the integration of the findings from both studies by highlighting whether the views demonstrated in study 1 were supported by the responses generated in study 2. The table shows that six of the nine domains identified as important in study 1 were supported by responses from study 2.

Principal findings

Midwives perceived a multitude of barriers and facilitators to carrying out HePPBes. Key barriers were requirements to perform an increasing amount of HePPBes on top of existing clinical work load, which impacted on the time available, midwives’ cognitive resources and the quality of relationships with pregnant women. Organisational issues such as a lack of continuity of care and difficulty accessing appropriate training were also identified. Key facilitators included midwives’ motivation to support pregnant women to address their health. Study 1 also highlighted strategies that midwives use to overcome the barriers they face in carrying out their HePPBes. Some findings were considered both barriers and facilitators as mixed views were expressed about whether certain health promotion topics should be addressed by other health professionals prior to pregnancy, women’s receptiveness to HePPBes during pregnancy and the social influence of midwives’ own health status.

Strengths and limitations

The complimentary nature of the two presented studies is a strength. Study 1 provided detailed insight from a group of midwives working in a community setting which was supplemented in study 2 by free text commentary from a larger sample of midwives, employed within a variety of professional roles.

Limitations include the difficulty to specify target behaviours when simultaneously investigating multiple HePPBes for a variety of health promotion topics at the same time. The use of the TACT principle [ 16 ], and the image within the A4 prompt card provided midwives with a visual aid to remind them of the study focus during the interview. The sample size in study 1 was based on evidence-based guidelines [ 22 ], but is smaller than other qualitative TDF-based studies [ 23 , 24 ]. In addition, the midwives who took part in study 1 were recruited from a single out-patient maternity clinic in Scotland and different and additional barriers and facilitators might have emerged within different contexts.

Study 2 used online recruitment which prevents checking that participating individuals fully met inclusion criteria. The current paper examined HePPBes at a general level but some of the barriers raised were health promotion topics specific (e.g. a lack of dietary services to refer women to). Future research could further explore similarities and differences of HePPBes for different health promotion topics.

Relation to other studies

Limited evidence exists on the psychological factors associated with midwives HePPBes targeting women’s multiple health behaviours. Previously identified barriers to midwives undertaking HePPBes including a lack of time, resources and variability in training quality [ 6 ] were confirmed in the current study and therefore highlight a continued need for midwives to be provided with support. Uncertainty amongst midwives about their public health role [ 7 , 8 ] was also demonstrated through the mixed views midwives expressed regarding whether all HePPBes should fall under the remit of the midwife. Midwives’ use of strategies to overcome the barriers they face in carrying out HePPBes has not been previously reported.

Examining multiple HePPBes increases the complexity of the behavioural influences identified and provides greater understanding of the influences on midwives HePPBes. The complexity of investigating multiple HePPBes is demonstrated by the higher number of barriers identified within the current study compared with studies which have used the TDF to explore midwives’ behaviours in relation to single health risk topics [ 11 , 13 , 14 ].

The TDF [ 10 ] provides an overview of the main psychological constructs explaining health behaviours. However, the theories that these constructs belong to are mainly used to explain single behaviours. Multiple behaviour change processes such as goal facilitation [ 25 ] and goal conflict [ 26 ] and transference [ 27 ] have not been captured by the TDF domain interview questions and therefore might have been missed by the current study.

Possible mechanisms and implications

Barriers such as difficulty to access HePPBe-related training suggest a specific public health component in midwife training or after qualification may be useful. The finding that carrying out HePPBes can be taxing suggests that more support for midwives may be required. Policy makers and key stakeholders commissioning midwives’ continuous professional development opportunities could provide HePPBe support in multiple formats (e.g. through training, handheld materials or peer support).

Given the variations in the type of care that midwives provide, the pressure placed on maternity services by midwives attending training and the limited time that midwives would have to access support, developing handheld (or electronic) materials may be the most feasible option. For example, a leaflet containing examples of the strategies midwives use to carry out their HePPBes, that midwives could refer to during or outwith antenatal consultations, could capitalise on some of the HePPBe facilitators identified within this study.

Unanswered questions and future research

The development of an intervention to support midwives in helping pregnant women address multiple health behaviours is necessary to maximise the effectiveness of public health interventions aimed at behaviour change during pregnancy. Future studies should translate the current findings into acceptable, scalable and effective interventions to support midwives to perform HePPBes.

The findings suggest that despite high levels of motivation to carry out HePPBes, midwives perceive numerous barriers to carrying out these tasks in a timely and effective manner. Interventions that support midwives by addressing key barriers and facilitators to help pregnant women address their health behaviours are urgently needed.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Consolidated criteria for reporting qualitative research

Health promotion practice behaviours

• Theoretical domains framework

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Acknowledgements

The authors are grateful to the Royal College of Midwives and everyone who supported the recruitment of midwives. The authors would like to thank all the midwives who were interviewed and undertook the questionnaire. The authors would also like to thank Angelica Setterington for her support in transcribing the interviews. This work was undertaken by and on behalf of The Scottish Improvement Science Collaborating Centre (SISCC).

This study was funded by the University of Stirling in collaboration with the Scottish Improvement Science Collaborating Centre. The Scottish Improvement Science Collaborating Centre (SISCC) is funded by the Scottish Funding Council (SFC), Chief Scientist’s Office, NHS Education for Scotland and The Health Foundation with in-kind contributions from participating partner universities and health boards. The grant reference number is 242343290 was received from SFC on behalf of all funders.

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Julie M. McLellan & Ronan E. O’Carroll

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Helen Cheyne

Faculty of Kinesiology, University of New Brunswick, Bathurst, Canada

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Contributions

JM contributed to the design of the study, carried out data collection and analysis and was primarily responsible for drafting the manuscript. SD contributed to the design of the study, was involved in data analysis and commented on drafts of the manuscript. RO’C and HC were involved in designing the study and commented on drafts of the manuscript. All authors read and approved the final manuscript.

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Ethics approval and consent to participate.

The University of Stirling Psychology Ethics Committee approved study 1 and NHS Research and Development approval was granted by Greater Glasgow and Clyde Health Board (R&D reference: GN16OG406). The University of Stirling’s General University Ethics Panel approved study 2 (GUEP316). Consent to participate was obtained from all midwives who took part in the studies.

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Consent for publication was obtained from all midwives who took part in the studies.

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Additional files

Additional file 1:.

Study 1 Interview Topic guide. (DOCX 19 kb)

Additional file 2:

Study 1 Prompt card. (DOCX 2283 kb)

Additional file 3:

COREQ checklist. (DOCX 18 kb)

Additional file 4:

Study 1 table of midwives view statements table. (DOCX 18 kb)

Additional file 5:

Study 1 table of midwives HePPBe strategies. (DOCX 16 kb)

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McLellan, J.M., O’Carroll, R.E., Cheyne, H. et al. Investigating midwives’ barriers and facilitators to multiple health promotion practice behaviours: a qualitative study using the theoretical domains framework. Implementation Sci 14 , 64 (2019). https://doi.org/10.1186/s13012-019-0913-3

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Public health and wellbeing: A matter for the midwife?

Katy Crabbe

Midwife, Salisbury Foundation Trust

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Ann Hemingway

Senior Lecturer, Public Health HSC Bournemouth University

This paper will provide a critical narrative review of public health interventions in pregnancy and the role of the midwife in public health. The historical and political context of public health and midwifery will be examined to give a background to the current midwifery public health agenda. The article will identify specific public health interventions used in pregnancy by midwives and assess how midwives perceive their role in implementing them.

Midwives are important public health practitioners, who alongside other agencies can make a long-term, positive contribution to the life course of women and their families.

Public health is an important part of the midwife's role. Naidoo and Wills (2000 : 181) define public health as:

• A concern for the health of the whole population
• A concern for the prevention of illness
• A recognition of the many social factors which contribute to health.

Wanless (2004) takes the traditional view of public health further and places responsibility on society, organisations, communities and individuals to implement public health improvement through their organised efforts. Thus every individual has a role in public health and should take responsibility for health promotion, disease prevention and prolonging life.

Public health seeks to protect and improve the health of communities, identifying causes of poor health, disease and illness in a population and examining it from the wider social and economic standpoint. It makes links between factors such as employment and education to the level of health and wellbeing in and across populations, with the aim of positively impacting the wider social determinants of health and wellbeing.

Pregnancy and the postnatal period offers maternity care providers the opportunity to maximise the health and wellbeing of women and their families. Women may see many different health professionals during their pregnancy but the midwife is in a unique position to be able to build a relationship and have an impact on public health-both in the short and long term through continuity of care.

However, in 2012 there were 694 241 babies born in England, but the number of midwives working in the NHS in 2012 was only suitable for 565 245 births ( Royal College of Midwives (RCM), 2013 ). The midwifery workload is further burdened with the higher numbers of complex pregnancies. These factors may potentially affect the equality of provision of maternity services in the UK.

The focus of a public health intervention in developed countries is less about managing contagious disease, as it was in the past, but about managing and preventing health conditions through surveillance and the promotion of healthy lifestyles and communities; therefore promoting positive long-term health outcomes.

Public health interventions are varied in pregnancy and range from smoking cessation support, identification of mental and emotional health problems to supporting families where domestic abuse has been identified. Midwives are also involved in identifying female genital mutilation (FGM), promoting healthy eating and weight and promoting breastfeeding. Screening in pregnancy, whooping cough and flu vaccination are other public health interventions carried out on a daily basis in maternity care.

The political and historical context of midwifery and public health

Public health has been central to maternity services throughout history, despite not always being recognised or acknowledged.

In the late 1880s, The Midwives' Institute (now the RCM) campaigned for the training and practice of midwives to be regulated, which resulted in the Midwives Act (1902) and the Maternal and Child Welfare Act of 1918 ( Hendrick, 2003 ). This enabled regulation of a profession in which many practitioners were unqualified and uncertified. There was little in the way of preventative antenatal care that identified medical and obstetric conditions and it was not until the 1920s that systematic attempts at providing a schedule of antenatal care succeeded ( McIntosh, 2010 ). By the 1930s a national maternity service had been established, coordinated by local public health authorities, and provided in the homes of women and families. However, over the next few decades midwifery gradually moved into a more institutionalised and medicalised model of care ( Johanson et al, 2002 ). The dominating public health messages at this time revolved around reducing neonatal and maternal mortality. Maternal and child welfare, health visiting, school medicine, venereal diseases and learning disabilities were the main population health concerns ( Harris, 2004 ).

Changing Childbirth ( Department of Health (DH), 1993 ) initiated the move away from the medicalisation of maternity care back towards normalisation and services that were flexible and responsive to the families they cared for. As a result, public health once again became a more visible part of the midwife's role.

Today, there is an increasing emphasis on the psychological and social needs of pregnant women. For midwives, evidence such as the Confidential Enquiry into Maternal and Child Health (CEMACH, 2004; 2007) supports the impact that public health has on mortality and morbidity of women and babies and requires maternity services to act to reduce risk.

Furthermore, Public Health England is encouraging every nurse, health visitor and midwife to become health-promoting practitioners by using their knowledge and skills to improve the health and wellbeing of the public ( DH, 2013a ).

Politics and policy drive the public health agenda in the UK. The recent compassion in practice guidance ( DH, 2013b ) focuses on reducing inequalities through improving maternal and population health. It confirms that partnership working between agencies, rather than midwives working in isolation, is the most successful approach to ensure the best start in life and achieve a healthy life expectancy.

What does being healthy in pregnancy mean?

All health professionals should have an understanding of the concept of health. Midwives particularly are aware of looking holistically at an individual to gauge the health of the woman and her unborn child.

There are many definitions of health, the World Health Organization (WHO) first attempted to define health in its broader sense in 1946 as:

‘A state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.’

Although the WHO definition started a change in the traditional thinking that good health encompassed the absence of disease, the inclusion of the word ‘complete’ means that it would be unlikely an individual could be healthy for a reasonable length of time ( Üstün and Jakob, 2005 ). Huber et al (2011) describes health as the ability to adapt and self-manage in the face of social, physical, and emotional challenges. In comparison, Baggot (2011) divides the traditional biomedical concept of health to a positive perspective, which also considers the social, environmental and psychological aspects of health. Other definitions agree that health is holistic and includes different dimensions, each of which need to be considered ( Naidoo and Wills, 2000 ).

On the understanding that health is more than the absence of disease, it is appropriate that approaches to public health are based on participation, collaboration, cooperation and empowerment for them to be effective ( Davies and Foley 2007 ). Pregnancy is potentially the only time women come into contact with health professionals on a regular basis for an intense period of time. It provides a unique opportunity for women to make lifestyle changes with the support of a health professional. However, it must be considered that each pregnancy is different and each woman has different needs that may affect her pregnancy.

Pregnancy and wellbeing

Although subjective, the two main approaches to wellbeing measure the extent to which physical and psychological needs are met, as well as the realisation of potential or the ability of a person to evolve and flourish ( Hemingway, 2011 ). WHO (2008) identifies several areas that have an impact on health and wellbeing, pregnancy and early childhood experience. A child's experience in its early life sets a foundation for the entire life course. A child's early physical, social, emotional and language development, strongly influences outcomes through life ( Allen, 2011 ). The social determinants of health are the distribution among the population of social and economic conditions which affect a populations health and wellbeing, such as local economy, culture, community and lifestyle ( Barton and Grant, 2006 ).

In relation to the role of public health and midwifery, stress in pregnancy, poverty and social exclusion are known to be linked to preterm delivery, low birth weight and higher rates of maternal mental health problems ( Al-Saleh and Renzo, 2009 ), all of which affect a child's early life experience. Thus, where a woman lives, her employment status, her networks within a community and the lifestyle and demographics of people living in her population will have an effect on her health and that of her unborn baby.

McCulloch's (2001) study of social gradients and teenage pregnancy illustrated that teenage pregnancy and teenage parenting show social gradients in the expected direction with high rates of pregnancy associated with high levels of deprivation. In another study, Spencer (2006) , noted that women who had been in a manual working class social group at birth were more likely to be affected by other negative social gradient factors throughout their life course.

It is not always one determinant that affects health outcomes. It is therefore vital that midwives work in partnership with other agencies such as health, social and voluntary agencies as this is key to empowering and supporting women to enable good health and wellbeing. This may be through helping women to widen their social networks, manage finances or through health promotion. In addition, it is important to have an awareness of the context of the individual or population's lives, including where they live, the economic situation and social support.

It is therefore important that maternity services place the mother and her baby at the centre of care, and plan and provide services to meet their needs ( DH, 2004 ). The focus for midwives must be on the woman as an individual, while taking into account the context within which she lives her life. Therefore consideration needs to be given to her health, her wellbeing and the factors that might affect them.

Midwives and their public health role

Midwives are experts in taking a holistic view of the woman and her baby, identifying pregnancy-related health needs and referring to medical colleagues when required. Midwives support ‘populations’ of women who have differing expectations and needs, for example pregnant teenagers or travelling communities. They also care for groups of women who have specific health needs, such as mental health problems, where specific tailored care is required for that group.

Despite evidence that links the importance of midwives in having a public health role ( International Confederation of Midwives, 2012 ), midwifery's dominant influence is the medical model of care, without an acknowledgment of the social context in which childbirth occurs ( Kitzinger, 2005 ). The acknowledgement of public health strategies should be central to midwifery practice if midwives are to positively influence long-term health outcomes of women and their families. However, Carlson (2005) highlighted the professional and structural barriers to midwives recognising their contribution to public health. The Nursing and Midwifery Council (2008) is clear that midwives should be actively encouraging women to think about their own health and the health of their babies and families, and how this can be improved as well as providing the traditional biomedical care.

McNeill et al (2012a) completed a systematic review of public health interventions in midwifery. They identified 36 systematic reviews that examined a diverse range of public health interventions. The review's overarching finding was that gaps exist in knowledge around the impact of midwifery practice on public health outcomes. The review identified limited systematic evidence to support the implementation of midwifery interventions and highlighted the difficulty in measuring impact due to some interventions not being well evaluated. Throughout the research, similar themes can be noted which include lack, or perceived lack, of knowledge, confidence in delivering public health strategies and the research focus on the biomedical element of midwifery practice, with limited research on midwives' delivering public health strategies. Studies that explore midwives preparation for their public health role are relatively limited. McNeill et al (2012b) used mixed methods to examine the public health education in pre-registration midwifery, finding that it was generally not taught as a separate subject but combined with other aspects of the course. This is an important point if midwives are to address the public health agenda and improve outcomes; it is vital that they are equipped with the theoretical knowledge at the start of their career to proceed.

A plethora of policies and documents have been released by the Government which focus on public health, in order to reduce health inequalities and increase long-term health outcomes at the individual and community level ( Wanless, 2004 ; DH, 2009 ; DH, 2010 ; Marmott, 2010 ; DH, 2011 ). Topics such as breastfeeding, obesity, early intervention and FGM are frequently discussed.

Domestic abuse

The identification of domestic abuse is a key public health issue in which midwives are central. More than 30% of domestic abuse begins in pregnancy ( CEMACH, 2007 ), having a significant impact on the woman and her unborn baby's physical and emotional health. Caution should be exercised when looking at statistical evidence surrounding domestic abuse as it is evidenced to be under reported ( WHO, 2005 ). However, this further illustrates a potential for midwives to fulfil their role as being key to identifying and supporting women where domestic abuse is present. Domestic abuse in pregnancy is defined as any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality ( Walby and Allen, 2004 ).

Lazenbatt (2005) examined how midwives perceive their role in raising the issue of domestic abuse with women. In a study of 448 midwives from different areas of practice only 28% of midwives directly raised the issue of abuse with women. The presence of a partner was identified as a main barrier to routine questioning; this is supported by the evidence ( Stenson et al, 2001 ; Salmon et al, 2006 ) and is a challenging barrier to overcome. Salmon et al (2007) also identified midwives' concerns around personal risk in domestic abuse situations specifically as many midwives are lone workers. When questioning midwives about their perceived role in identifying domestic abuse, Lazenbatt et al (2005) noted that confidence was a major factor in dealing with issues around addressing domestic abuse. Buck and Collins (2007) completed a systematic review of 13 studies examining midwives' identification of domestic abuse and agreed that confidence was an issue for practitioners but also identified time being a factor in midwives' ability to address domestic abuse. Historically, midwives have found it difficult to identify child or domestic abuse. However, in a 5 year follow-up of the Bristol Domestic Abuse Enquiry Programme, researchers noticed that midwives had begun to feel more confident in their ability to ask about abuse in the home as well as a statistically significant increase in selfreported knowledge on how to deal with disclosure of violence ( Baird et al, 2013 ). This illustrates that with the instigated mandatory training throughout the UK, midwives are becoming more proficient at carrying out this vital public health enquiry and providing interventions to deal with disclosure. A Swedish study by Finnbogadottir and Dykes (2010) looked to explore midwives' awareness of a clinical experience regarding domestic abuse and supports the view that continuous education and professional support is vital.

Smoking cessation

Smoking remains one of the few modifiable risk factors in pregnancy; however, just over 12.7% of women still smoke in pregnancy in the UK ( Health and Social Care Information Centre, 2014) . These figures, looking at smoking status at time of delivery note that this is the lowest rate in 8 years indicating that the public health message may be getting through. Midwives' perceptions of their role in giving smoking cessation advice has shown to be dependent on the outcome of advice previously given, personal experience and their relationship with the client ( Herberts and Sykes, 2012 ). Midwives were not noted to perceive smoking cessation support as a negative part of their role but often prioritised other areas due to the extent of their responsibilities. This is a common theme in research on midwives and public health, with prioritisation going to the biomedical aspects of the midwife's role. It has been evidenced that the majority of midwives feel a professional responsibility to intervene with smokers but felt that there are often personal and organisation barriers to providing an effective service ( Bull, 2007 ).

Perinatal mental health

Perinatal mental health as a public health concern has been highlighted through the confidential enquires into maternal deaths, with findings that point to suicide or psychiatric causes as the leading cause of maternal death in the UK ( Royal College of Obstetricians and Gynaecologists, 2004 ). In a study by Lavender et al (2001) , which assessed midwives' attitudes into taking a greater public health role by looking at specific areas including postnatal depression, the researchers found that midwives felt that they could make ‘a lot’ of difference. However, midwives did highlight the need for adequate training resources and time to implement changes. Jones et al (2010) agree; in their study of 815 Australian midwives' perceived lack of competence was considered to be the main barrier rather than lack of interest.

In a study that examined midwives' attitudes to assessing mental health problems in pregnancy, Ross-Davie et al (2006) surveyed 187 midwives working in inner London to answer the question: ‘are midwives ready for the development of their public health role in mental health?’ They found positive attitudes among midwives wanting to take on a more developed role. Midwives responded that they felt screening for mental health problems should be a core part of their role. As with findings in previous studies, midwives highlighted the need for increased education and training around identification and increasing confidence to support women. Midwives need to have an understanding of mental health conditions to be able to screen effectively, identify symptoms and be able to refer appropriately. In a further study by Elliott et al (2007) following a training session for midwives, an improvement was noted in recording of mental health problems in the notes. This, however, was a service innovation and not performed as a research study so it is difficult to ascertain the reliability of results. However, this provides some assistance in promoting the need for further research into training and the provision of resources to assist midwives to realise their full potential in perinatal mental health screening.

Home visiting, parenting programmes and peer support have all been shown to improve perinatal mental health outcomes ( Elkan et al, 2000 ; Barlow et al, 2004 ; Shaw et al, 2006 ; National Institute for Health and Care Excellence, 2007 ; Olds et al 2007 ). Exclusive breastfeeding also has been found to reduce the incidence of postnatal depression ( Figueiredo et al, 2013 ) as long as the woman did not have a negative breastfeeding experience ( Watkins et al, 2011 ).

Both research and policy point to public health having a greater prominence in the midwifery agenda. Internationally, the midwifery agenda is focusing on the importance of midwives and their role in improving the health of mothers and babies ( DH, 2013b ). In the UK, compassion in practice and the importance of adopting the 6 Cs into everyday midwifery care remains a high priority ( Cummings, 2012 ) to ensure safe transparent care. Although midwives have always provided public health interventions, it has not always been recognised that they are pivotal public health practitioners. The evidence concludes that research is still scarce on midwives and public health, particularly around perceptions of their public health role. However, the available research shows that midwives are increasingly engaging with the public health agenda. Barriers have been identified and midwives themselves note that public health strategies are difficult to deliver due to constraints on time and resources as well as training and education.

To be effective, midwives need to be able to work in collaboration with other agencies such as social care and voluntary services. Commissioners and managers should consider the evidence for specialist midwives who focus on the health of the local community and who would enable targeted action for vulnerable groups. Educational establishments must ensure that public health is high on the agenda for midwifery students' education so that they have the tools and knowledge to see themselves as pivotal public health practitioners.

Midwives are in a unique position to support women to make healthy choices throughout their pregnancy and beyond to prevent ill health and promote health in line with the increasing recognition of the importance of maximising health for infants and children at the start of their lives. Midwives provide a range of public health interventions on a regular basis, but do not always place this intervention in the public health context, considering the long-term wellbeing of maternal and infant health. Midwives, managers and public health authorities all need to take responsibility for midwives to become a more pivotal part of the public health team.

• Public health is central to the role of a midwife but it is often not acknowledged
• Midwives must recognise that the needs of each individual are very different and the woman should be at the centre of care
• Midwives must work in partnership with other agencies and not in isolation to affect public health outcomes
• The role of the midwife and public health has an impact on a child's life course
• Confidence and training are required to address domestic violence, smoking cessation and mental health problems

• Research article
• Open access
• Published: 07 December 2012

Public health education for midwives and midwifery students: a mixed methods study

• Jenny McNeill 1 ,
• Jackie Doran 1 ,
• Fiona Lynn 1 ,
• Gail Anderson 1 &
• Fiona Alderdice 1  

BMC Pregnancy and Childbirth volume  12 , Article number:  142 ( 2012 ) Cite this article

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Current national and international maternity policy supports the importance of addressing public health goals and investing in early years. Health care providers for women during the reproductive and early postnatal period have the opportunity to encourage women to make choices that will impact positively on maternal and fetal health. Midwives are in a unique position, given the emphasis of the philosophy of midwifery care on building relationships and incorporating a holistic approach, to support women to make healthy choices with the aim of promoting health and preventing ill health. However, exploration of the educational preparation of midwives to facilitate public health interventions has been relatively limited. The aim of the study was to identify the scope of current midwifery pre registration educational provision in relation to public health and to explore the perspectives of midwives and midwifery students about the public health role of the midwife.

This was a mixed methods study incorporating a survey of Higher Educational Institutions providing pre registration midwifery education across the UK and focus groups with midwifery students and registered midwives.

Twenty nine institutions (53% response) participated in the survey and nine focus groups were conducted (59 participants). Public health education was generally integrated into pre registration midwifery curricula as opposed to taught as a discrete subject. There was considerable variation in the provision of public health topics within midwifery curricula and the hours of teaching allocated to them. Focus group data indicated that it was consistently difficult for both midwifery students and midwives to articulate clearly their understanding and definition of public health in relation to midwifery.

Conclusions

There is a unique opportunity to impact on maternal and infant health throughout the reproductive period; however the current approach to public health within midwifery education should be reviewed to capitalise on the role of the midwife in delivering public health interventions. It is clear that better understanding of midwifery public health roles and the visibility of public health within midwifery is required in order to maximise the potential contribution of midwives to achieving short and long term public health population goals.

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Background (5090)

UK policies [ 1 – 3 ] have increasingly recognised the importance of maximising health for infants and children at the start of life, and more recently since the Marmott review of health inequalities [ 4 ]. Internationally, there has been a similar focus in recent policy [ 5 , 6 ] and also seen in a report by the World Health Organisation [ 7 ]. Ensuring infants have a good start in life is at the cornerstone of good maternity care, as the origins of adult ill health have been linked with intrauterine fetal development, particularly size at birth, which is often referred to as the Barker Hypothesis [ 8 , 9 ]. Opportunities for all maternity care professionals exist to maximise both infant and maternal health throughout the perinatal period and address inequalities. However, midwives specifically have the potential to contribute significantly, given the centrality of building relationships with women within midwifery care [ 10 ] and the focus on promoting health [ 11 , 12 ].

Despite acknowledgement that public health is integral to midwifery [ 13 , 14 ] and a renewed emphasis on the contribution of maternity care to addressing health inequalities [ 15 , 16 ], key aspects of the public health role of the midwife have not been examined extensively in the research literature and, to date, limited attention has been given to how midwives recognise their contribution to public health. There are examples of midwifery led interventions, for example, weight management intervention [ 17 ], promoting maternal mental health [ 18 ] and innovative practice, such as, the partnership of the Royal College of Midwives (RCM) UK and Slimming World to support women [ 19 ]. However these are often not reported from a public health perspective and as a consequence, they may not be recognised by midwives as contributing to public health targets. In order to realise how midwives function as agents of public health and view their contribution to public health, it is important to explore the current education for midwives and how this prepares them for practice.

This study of midwifery education in relation to public health followed a review of midwifery practice across the UK [ 15 ], which involved conducting a systematic review of systematic reviews in relation to the public health role of the midwife [ 20 – 22 ]. A detailed study report was provided for the funders on completion of the study [ 23 ] which highlighted the need to clearly articulate the public health role of the midwife in education and in practice. The aim of this paper is to present the key findings relative to the scope of current educational provision in relation to public health and inequalities for pre registration midwives and, secondly, to explore the perspectives of midwives and midwifery students about public health.

Methodology

The project comprised of two phases: a survey of all Higher Education Institutions (HEI’s) in the UK providing pre registration midwifery education, alongside focus groups with midwifery students and registered midwives across the UK. An Advisory Group (UK wide) was established and served to provide expert guidance on the project. Ethical approval was granted from the School of Nursing & Midwifery, Queen’s University Belfast Ethics Committee (Application Number: 0712010) and informed consent was sought from all participants.

Design & sample

The aim of Phase 1 was to explore the current provision of public health education within pre registration midwifery curricula across the UK. A survey was constructed, which included both closed and open ended descriptive questions relating to the nature of public health education in pre registration midwifery curricula, with particular reference to topics, hours allocated, importance of public health to midwifery and gaps or limitations. Validated questions were used from a previous survey exploring public health education in Scotland and were piloted prior to commencing. The sample for Phase 1 was identified by contacting The Higher Education Statistics Agency (HESA) and searching the web pages of all UK HEI’S. A cross check was performed with the Nursing and Midwifery Council (NMC) Register of ‘Lead Midwife for Education’ (LME) database available on the NMC website ( http://www.nmc-uk.org/Nurses-and-midwives/Midwifery/Midwifery-Education-and-Practice/Lead-Midwives-for-Education-LMEs ) to ensure there were no omissions. Sixty HEIs in the UK were eligible (England: 46; NI: 2; Scotland: 8; Wales: 4).

Data collection & analysis

An invitation pack, including a letter of invitation, an information leaflet, a consent form and a copy of the survey, was posted to all identified institutions (n=60). Respondents had the option of completing the survey manually and returning in a prepaid envelope, completing it over the telephone with a member of the research team or completing it online via survey monkey. The project team also offered participants the option of completing the survey on the LME’s behalf by accessing the institutions’ curriculum documents. In this event, the survey was returned to the institution for approval before data analysis. Follow up telephone calls or emails were employed approximately 2 weeks later. Data collection commenced in January 2011 and was completed by April 2011. Data were entered initially to MS Excel and transferred to SPSS (Version 18) for analysis. Basic descriptive statistics were conducted and data from open ended questions were categorised thematically.

Design &sample

In Phase 2 the aim was to conduct focus groups across England, Scotland, NI and Wales with midwives and with midwifery students to ascertain their perspectives on how education around public health and inequalities relates to practice and service delivery. The samples for the focus groups were recruited from the Royal College of Midwives (RCM), UK and selected institutions providing midwifery education. The RCM facilitate regular meetings with the country specific Boards (England, NI, Scotland and Wales) including, for example, Clinical Leads, Heads of Midwifery (academic and clinical), Consultant Midwives and Supervisors of Midwives. The RCM offices in England, Scotland, Wales and NI were contacted to arrange the focus groups and distribute the email invitation. The LME in each of the selected institutions was contacted to introduce the study and invite midwifery students to participate.

The focus groups (conducted by JD, FL, GA & JM) were audio recorded and transcribed into MS Word independently. A schedule was designed to be used as a loose topic guide and to act as a prompt if required. Data collection commenced in January 2011 and was completed by April 2011. The transcripts were analysed by content primarily by JM with input from all members of the project team regarding emerging categories. Content analysis involves the identification of key topics or categories within the transcripts and then looking for relationships within the categories [ 24 ].

Of the sixty institutions identified, 55 were eligible as they currently offered pre registration midwifery education. A total of 29 institutions responded (53%) in relation to 37 programmes (3 year and 18mth programmes), of which 23 were in England, 3 in Scotland, 2 in Wales and 1 in NI. Participants responded in a variety of methods: 15 (52%) replied via survey monkey: 10 (35%) via post: 3 (10%) sent their curriculum documents for completion by the project team and 1 (3%) completed over the phone.

Explicit reference to public health in midwifery curricula

The pre registration survey asked respondents to state how explicit (direct reference) the inclusion of public health was in the curriculum philosophy or programme and module aims/objectives. The results are presented in Figure 1 .

Explicit Inclusion of public health/inequalities in pre registration programme documentation.

Public health topics included

Respondents were invited to select from a list of pre defined topics on public health and inequalities and indicate whether they were included in their provision of pre registration education for midwives (Table 1 ). Participants were invited to indicate the approximate number of hours allocated to the list of topics. Table 1 demonstrates the considerable variation across institutions both in relation to the topics provided and the hours allocated, for example, three institutions stated they did not cover the principles of public health, five reported they did not include epidemiology and the number of hours allocated to perinatal mental health ranged from 1.5 to 14. A number of respondents also reported that several subject areas were not offered, as illustrated in Figure 2 .

Specific public health and inequality subject areas not offered* pre registration programmes.

Curriculum gaps and limitations

Respondents were asked to identify any gaps or limitations in the current provision of public health education. Twenty five (68%) respondents reported there were no gaps, six (16%) reported they felt there were gaps; and six (16%) did not respond. There was recognition that public health was explicit in institutional programmes, however, it was also reported that more time was needed to explore theoretical models and often learning was solely focused on practical aspects. Some respondents who reported that they felt there were no gaps in the curriculum also commented that the public health elements of their undergraduate curricula depended on good links with practice for example the facilitation of clinical placements which provide exposure to public health roles. It was highlighted that the curriculum needed to be regularly revisited in order to ensure relevance. Specific topic areas where gaps were identified by respondents included perinatal mental health, asylum seekers and homelessness, obesity, nutrition and alcohol.

Public health as core to midwifery

Respondents were asked to rate on a scale of 1–5 (5=essential) how much they thought public health was part of the core role of the midwife. All participants denoted a score of 4 or 5 with the exception of one, indicating the majority considered public health as an essential element of core midwifery practice.

Nine focus groups with 59 participants (34 midwifery students and 25 registered midwives) were conducted. Four focus groups with students were conducted in three participating institutions (England, NI and Scotland) and five focus groups were held with registered midwives; participants included managers, midwives from practice, public health specialists and educationalists in England, NI, Scotland and Wales. Data from the focus groups are presented in relation to three key themes: understanding public health in midwifery; the reality of practice; knowledge and confidence about public health.

Understanding public health in midwifery

Throughout the group discussions it was evident that midwifery students did not have clear understanding of the public health role of midwives. In some groups, initially it was seen as a specialist area and not as core, given that midwives cannot be ‘experts’ in all areas. However, as the discussions continued within groups, there eventually (and usually) was consensus that public health was integral to midwifery practice and input from multidisciplinary teams or specialists could be utilised for additional support.

“I think the role of the midwife is really important but when I was doing my bit of research for my assignment one of the key things that was out there, a lot of midwives don’t accept that they have a role in public health” (Scotland Student Group)

In all of the focus groups with registered midwives the definition of public health relative to midwifery was difficult to pinpoint precisely and generally the question was met by initial silence. One group identified that it was important for midwives to have ‘their’ definition of public health and what it means in midwifery practice as other disciplines have a clearer understanding of what public health is.

“So I think what midwives need to do is (consider) what is our meaning, our understanding, our domain, what is our package of public health? What do we mean by it? What would be our targets? What would we want to see as perhaps, we can’t control the whole population but we can look at the whole of childbirth, say from maybe a little bit of preconception right up to is it midwives’ role up to 28 days after birth? What kind of targets, goals, public health things would fit in?” (England Midwifery Group)

Discussions with registered midwives were generally consensual about public health as an aspect of midwifery practice, although, there was often debate as to the extent of this role and boundaries regarding core or specialist practice. Terminology, such as ‘crucial’, ‘pivotal’, ‘the foundation of it’, ‘significant role’, was used to describe the public health role of the midwife in relation to the core aspect, although, within groups there was confusion relating to if and how midwives viewed themselves as public health practitioners.

‘It’s got to be the core function and then we build on top of that’ (Wales Midwifery Group)

One group discussed how difficult it was to marry the goals of public health and the aim of holistic midwifery care. It was proposed that the goals of public health are overarching and at population level, whereas in midwifery care the aim is more towards an individualised approach tailored to the specific needs of women and their families, and therefore, this may result in conflict (see quote below). This was not discussed voluntarily in subsequent groups, however, the moderator of the final focus group introduced the idea and the concept was generally agreed.

“.....public health tends to take a very global approach and they want everybody vaccinated and everybody to give up smoking and everybody to breast feed. And the reality is that midwives, we’re actually dealing with individuals who are giving us very good reason for why they’re going to continue smoking and why they’re not breastfeeding which may not fit with the public health agenda. I think that there’s a fundamental problem between imposing that perhaps, on a midwife who is actually working with an individual and understands that woman’s context. Yes, she knows it’s not good for her to smoke. Yes, she knows it’s going to give her cancer or whatever in the long term but right now she’s just trying to survive. And I think trying to superimpose this public health practitioner role on a midwife could actually lead to role confusion or completely role rejection”. (Scotland Midwifery Group)

The reality of practice

A general lack of confidence and some anxiety around discussing specific public health related topics with women was reported by midwifery students at various stages of their training e.g. smoking cessation.

“I’ve completely avoided that huge area of public health and midwifery and I feel terrified of it now, you know, if I were to get a woman who was saying, ‘I’m smoking, what can I do about it’... I wouldn’t know”. (England Student Group)

Students were also aware of the impact of busy clinical environments and the subsequent effect on the ability of midwives to address or discuss public health issues.

“I think time’s a big issue with all public health. I think midwives don’t have enough time to deal with all the public health issues that they need to deal with” (NI Student Group)

Although it was generally recognised that public health interventions and addressing inequalities are part of the midwives’ role, barriers in clinical practice were identified as influential on the effectiveness of that role. Barriers discussed included the shortage of time available clinically to care for women, the difficulty of providing copious health promotion messages at the booking interview, the ‘tick box’ approach to care, midwives’ reluctance to develop conversations with women due to a lack of time, continual ‘adding onto’ the midwives’ role, models of care and the lack of vision regarding long term outcomes of care. Additional barriers were identified that focused more generally around professional issues, such as, heavy administration and bureaucracy, work load volume and leadership. However, despite the recognised barriers, groups were unanimous that pregnancy was a time of opportunity for midwives to promote the overarching goals of public health. The recognition of pregnancy as a time of ‘opportunity’ was resonant through all the focus groups and there was unanimous agreement both within and between groups that pregnancy is a time in women’s lives which could be influenced with regard to a public health message.

“You know, I think what we do have as midwives is a captive audience. We have an opportunity. We engage with women, somewhere in and around six to twelve weeks in their pregnancy depending on how early they do their pregnancy test and who they contact first. And we have access to those women who are like sponges for information for at least six months and it is an opportunity” (NI Midwifery Group)

Knowledge and confidence about public health

The majority of students were able to discuss key public health topics relevant to midwifery practice and perceived their level of theoretical knowledge was good; however they reported that practical delivery was difficult. Several groups suggested some additional solutions, such as, motivational interviewing or training in communication skills through role play as highlighted below.

“Participant 1: But it’s hard, I think, for us I think to go out and start telling people this. I think you need more than a, confidence lessons or something...

Participant 2: Or, just different approaches to how you go about health promotion. You know, do you ask how, what the woman knows about it first and getting into like dialogue and conversation as opposed to telling the woman what to do.

Participant 1: Yeah...yeah, so like more of the ‘how to’.

Participant 2: Yeah, definitely. Role play....I think that would be really good” (NI Student Group)

Barriers to increasing knowledge were identified by the focus groups with registered midwives. These related to the availability of training, difficulty releasing staff for training and the type of training that is needed. The majority of groups acknowledged that training exists, however, the topic is often politically motivated or a current hot topic, for example, the focus on obesity and weight management during pregnancy. Another issue raised was the availability of funding for training; funding was prioritised for courses where the aim was to develop skills of direct benefit to practice i.e. medical prescribing or examination of the newborn skills over developing theoretical knowledge, as illustrated by a quote from a NHS midwifery manager, below:

“If a midwife came to me and said I want to go and do a module at (a HEI) or wherever on public health, unless she was doing it as part of a degree I can’t see her coming forward to do it, and I couldn’t support her unless I had a particular role for her” (NI Midwifery Group)

There was a recognition that public health was more prominent on pre registration education curricula and that newly qualified midwives were perceived to be ‘steeped in public health” (Scotland) and ‘more conscious of public health than midwives trained a few years back’ (Wales). However other groups felt that while this may be true, there were concerns around the general lack of midwives’ confidence to discuss many public health issues with women, for example obesity, weight management, and routine enquiry about domestic abuse.

Some of the discussion in the focus groups (registered midwives) outlined potential measures to address the barriers in order to maximise the public health role of the midwife. Recognition of the need for more training was identified and several examples of innovative practice were provided. For example, a NHS service manager gave an example of how funding had been obtained through the British Heart Foundation for a midwife to link into a community based obesity networking and motivational programme.

Several methods of training to address gaps in the effectiveness of a midwifery public health role were suggested. Online training in the form of a toolkit was suggested in one group. This would have the advantage that midwives could access it in their own time. However, another group felt that online learning was problematic in the area of public health, as there was a need for an interactive element and also monitoring compliance with online learning could be difficult if the training was not mandatory. Increased knowledge of interventions that midwives could conduct was discussed as something that would be helpful. Brief intervention training, which has been used effectively in other areas of practice, was also raised as a potential for midwives in the area of public health. Underlying the recognition of training, however, was the need for more emphasis on the application of public health to midwifery and for all midwives to understand better the relationship between public health and midwifery.

“.....so I think the longer term thing would be to change the culture of how midwives see their role in public health and accept that and maybe see that it’s not an add-on to our role” (NI Midwifery Group)

“I think a lot of it too is, [that] you do have to get underneath the midwife’s thought processes as well, in it all..if they’re going to deliver the positive message you’ve got to understand them, haven’t you, as a person and build their confidence” (Wales Midwifery Group)

Following analysis of the results from Phase 1 and Phase 2, the findings were further considered comparatively in relation to the key themes emerging from each phase. This process resulted in identification of three clear issues which will require significant consideration from the perspective of policy makers, education providers, midwifery researchers and midwives in practice in order to maximise the public health role of the midwife moving forward. The themes are further outlined in the following paragraphs under broad headings: understanding the public health role of the midwife; visibility of public health in midwifery and the direction of public health education in midwifery.

Understanding the public health role of the midwife

It was consistently difficult for both midwifery students and registered midwives to articulate clearly their understanding and definition of public health in relation to midwifery. This lack of clarity created confusion around terminology in relation to public health and the subsequent application of the concept of public health in everyday midwifery practice. This was a similar finding to research [ 25 ] which explored perceptions of health promotion with midwifery students and reported a limited understanding of health promotion in the context of public health and lack of clarity around health promotion in midwifery practice, although, the sample size was small (n=8). In order to promote the public health role of midwives, further training in relation to public health awareness and how it relates to core midwifery practice will need to occur before any real progress can be made [ 26 ]. Within the focus groups it was clear that some midwives and the majority of midwifery students did not view themselves as public health practitioners or would not have described much of core midwifery practice as public health and, yet, the survey indicated that nearly all HEIs viewed public health as core to midwifery. The dissonance between the perspectives of educational providers and midwifery students and midwives is important to note and may explain some of the challenges reported when discussing public health topics in practice. To ensure the midwifery contribution to public health goals is valued it is vital that midwives and midwifery students recognise that much of what they do falls under the banner of public health and as such is acknowledged primarily by the midwifery profession but also other disciplines.

Visibility of public health in midwifery

The current pre registration curriculum refers to essential competencies which must be achieved in order to register with the NMC. The concept of public health is evident and underpins many of the requirements, for example students are required to ‘actively encourage women to think about their own health and the health of their babies and families, and how this can be improved’. The term public health is only explicitly used once: ‘planning and offering midwifery care within the context of public health policies (p26)’ [ 27 ]. Pre registration education in relation to public health is for the most part integrated into the curriculum with very few universities offering specific modules. Whilst this was acknowledged in the focus groups, as parallel to how midwifery and public health are related i.e. it underpins all of what midwives do, this integrated approach potentially raises concern if linked to the lack of clear definitions and value of the public health role of the midwife. The intrinsic embedded nature, whilst philosophically sound, may contribute to the lack of recognition or awareness about public health within midwifery.

This highlights a major challenge in relation to public health and midwifery and suggests that future work in midwifery education and practice must focus on promoting a clear, visible public health role as core to midwifery [ 28 ]. One of the key recommendations of the Public Health Midwifery 2020 Work Stream Report [ 28 ] indicated that midwives need to capitalise on the opportunity to deliver evidence based public health interventions. Although a systematic review of reviews on the public health role of the midwife [ 20 ] identified several midwifery interventions from review evidence that midwives could implement, generally, the evidence was very limited. A subsequent review [ 22 ] reporting on high quality effective interventions identified a clear need for further research in this area suggesting that the provision of pre registration midwifery education in relation to public health needs to be reviewed in order for midwives to have a clearer understanding of their public health role and subsequently evaluate their practice.

Direction of public health education in midwifery

Findings from the current study indicate there is reasonable consistency across the UK in terms of provision of pre registration education, which is to be expected given the NMC requirements for entry to the register as a midwife. Although the major topics are covered by the majority of HEI’s there was some variation in the provision of education for current hot topics e.g. obesity and weight management or maternal nutrition. This may reflect the time lag between what is current and the necessary administration around changing curriculum to meet NMC requirements or that pre registration curriculum are generally only renewed every 3–5 years However, this raises questions about the decision and rationale for inclusion of core and specialist topics. The role of specialist practitioners was referred to in the focus groups and this may be the mechanism to address the delay in translating current topics of interest in educational curricula. For example specialist practitioners could be routinely invited to present a guest lecture for midwifery students thereby increasing exposure to current work and relevant good practice. Brief Intervention Training, based on the principles of motivational interviewing to improve communication [ 29 ], was also suggested as a possible solution to improving training for midwives in relation to public health. This type of intervention has been reported previously as having potential to improve counselling by midwives on smoking cessation, as the observed communication styles (traditional, authoritarian and paternalistic) were not effective [ 30 ].

The Education Workstream Report from Midwifery 2020 [ 26 ] specifically noted ‘that knowledge and skills regarding public health and well-being need to be appropriately strengthened within pre registration programmes’ (p13). Public health education in relation to midwifery, which focuses more specifically on the public health role of the midwife rather than the current model, where the midwife is regarded as an agent who delivers health education or promotion messages, could potentially address some of the difficulties highlighted in this study. In addition it is important that public health is not seen as an added extra for midwives but as core to the philosophy of care [ 31 ]. Emphasising the public health role of the midwife would enable a better fit with the provision of midwifery care within a social model, taking into account the context in which health promotion or health education is delivered. Such training would enable midwives to visualise and apply the concept of public health to midwifery practice and improve their overall understanding of public health. Subsequent provision of care would then be framed in the context of impacting on long term health outcomes of the broader population [ 32 ].

Strengths and limitations

Designing the questionnaire for Phase 1 was challenging, as the aim was to collect relevant detailed data whilst balancing this with the completion time. The nature of the questionnaire required respondents to refer to curriculum document(s) and, therefore, was time consuming to complete. To ensure respondents received maximum support throughout the process, the researchers kept in close email and telephone contact. In addition, we attempted to maximise the return rate by providing various options for completing the questionnaire, including an online option and completion by the researchers through the use of relevant curriculum documents and/or telephone. Telephone and email reminders were also used to increase the response rate. In Phase 2 the focus groups were generally representative of both students and practitioners due to the variety of years of experience/education, gender as appropriate to a midwifery profile and current employment, although, some groups had small numbers. One country within the UK was not represented in the student focus groups and, therefore, may have provided additional perspectives had the time frame permitted approaching other institutions. The findings from this study may be limited to a UK setting; however, it could be easily replicated in other countries.

It is clear from this study that the current approach to public health education within pre registration midwifery should be reviewed in order to facilitate better understanding of midwifery public health roles and, therefore, maximise the visibility and potential contribution of midwives to achieving both short and longer term public health population goals. It is also essential for registered midwives to have a clear understanding of their public health role in order to implement and evaluate interventions and provide evidence based care. The findings from this study suggest that future research needs to explore mechanisms that would facilitate improved understanding by midwives of their contribution to public health and translation of knowledge into practice. The contribution of midwifery to public health has been relatively underplayed and, as the drive to meeting targets focusing on improving population health and reducing inequalities intensifies (particularly for children at the start of their lives), it is timely for midwives to recognise and assert the potential of their contribution.

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Acknowledgements

Funding for this study was provided by NHS Education for Scotland. The source of funding did not have any involvement in the design and conduct of this study, other than receiving progress update reports.

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All authors (JM, JD, FL, GA and FA) contributed to the conception and design of the study, data collection, analysis and interpretation; JM prepared the first draft of the manuscript and all other authors provided guidance and critical revisions. All authors approved the final version for submission.

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McNeill, J., Doran, J., Lynn, F. et al. Public health education for midwives and midwifery students: a mixed methods study. BMC Pregnancy Childbirth 12 , 142 (2012). https://doi.org/10.1186/1471-2393-12-142

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Home — Essay Samples — Nursing & Health — Health Care Policy — The Role of the Midwife in the Healthcare

The Role of The Midwife in The Healthcare

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Works Cited

• Alberta Association of Midwives. (2012). Midwives in Alberta: Practice Guidelines Handbook.
• Beattie, A. (1991). Health promotion models and values. Oxford University Press.
• Bowden, S. (2006). Midwifery and the promotion of normality. Elsevier Health Sciences.
• Davis, D. (2002). Continuing professional development for midwives: Challenges, opportunities, and strategies. Midwifery, 18(1), 4-8.
• Dunkley, C. (2000). Health promotion in midwifery practice: A resource for health professionals. Elsevier Health Sciences.
• Ewles, L., & Simnett, I. (2003). Promoting health: A practical guide. Elsevier Health Sciences.
• Health Care Providers Handbook. (2010). Cultural sensitivity.
• Nursing and Midwifery Council. (2008). The Code: Standards of conduct, performance, and ethics for nurses and midwives.
• Royal College of Midwives. (2000). Vision 2000: A blueprint for the future of midwifery.

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Promoting midwifery, quality maternity services and professional standards

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Public health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society” (Acheson, 1988; WHO)

In other words, public health seeks to identify risks to health and find the best ways to minimise them, in order to give everyone the best chance of leading a healthy life.   This is generally undertaken by work such as:

• Health protection -  protecting people's health from a variety of issues, including disease and infection
• Health improvement -  improving people's health, for example, by helping people quit smoking or reduce their weight
• Healthcare and public health -  ensuring that our health services are effective, efficient and equally accessible to all

In light of this, it's apparent that public health is a core part of the work that midwives do every day. The RCM commissioned a report in 2017, with funding from the Department of Health, England, to examine how midwives are working with public health in greater detail.

Stepping up to Public Health – project summary

The main aim of the project was to conduct a scoping and needs analysis; mapping the current public health activities of midwives and MSWs, services users and student midwives, using both qualitative exploratory work and quantitative surveys based on 35 core topic areas.

This was followed by the translation of the project findings into practical outputs to support improvements in the provision of care. These included the development of a public health model and associated resources, designed to assist practitioners in their work with women and their families. More information on the model and outputs can be seen below.

Overall there was general agreement across the four UK countries that a large proportion of midwives' work does fall under the remit of public health. Practitioners had a wide definition for the types of interventions and information topics that fell within this remit, and saw midwives' role as crucial for both the immediate care being provided and for the health of the family unit.

The project also found that midwives needed more time, confidence and training to discuss public health with women, to ensure information was given in a consistent and timely manner and that follow up was supported by continuity of care in conjunction with the multidisciplinary team. There were discussions on the difficulties experienced in getting tailored, specialist care and advice for women in areas including mental health and maternal weight, even if the vital referral pathways were established and available. Some of the accessibility issues stemmed from the waiting time for being seen after referral to the lack of expertise of a public health lead. The report concluded that the need for leadership at a consultant midwife level was a key factor in supporting successful public health work in maternity services.

What is Public Health?

Visit these sites for more information about public health:

• Health Careers, NHS Health Education England
• Public Health Services, World Health Organisation
• Public Health, Royal College of Nursing
• Knowledge and skills career framework, Public Health England

Improving Prevention and Population Health

The Maternity Transformation Programme’s Workstream 9 focuses on a range of initiatives to improve wellbeing, reduce risk and tackle inequalities from preconception to 6-8 weeks postpartum. The aim is to ensure every woman is fit for and during pregnancy, and that every family is well-supported to give children the best start in life.

The NHS Long Term Plan commits to strengthening its contribution towards prevention and tackling health inequalities, with specific action in a range of areas including smoking, obesity, infant feeding, maternal and paternal mental health.

How is the RCM involved?

Immunisation, including in pregnancy.

• the fetus, including prematurity, low birth weight and stillbirth
• the mother, due to serious complications of flu, in especially late pregnancy
• Pregnant women are offered the inactivated influenza vaccine to protect themselves and provide passive immunity to their baby in the first few months of life. Because of the changing nature of influenza viruses, they are modified according to the latest virus strains and in line with World Health Organisation (WHO) recommendations. Immunisation must be repeated with every pregnancy
• In 2011-2012 there was a marked increase in the number of cases of pertussis (whooping cough) in England. To help prevent further infant deaths, an emergency programme of maternal pertussis immunisation was introduced in October 2012. The vaccine is offered from 16 to 38 weeks gestations, although the optimal time is 16 to 32 weeks.

The RCM collaborates with the NHS and public health partners to support national campaigns aimed at maximising the uptake of vaccines during pregnancy. We also support public health initiatives encouraging NHS staff to be vaccinated.

Stopping smoking in pregnancy

• Smoking during pregnancy is closely associated with socioeconomic factors and is therefore a major health inequality. Supporting women to have a smoke-free pregnancy is vitally important for reducing infant mortality. It is the main modifiable risk factor for a range of poor pregnancy outcomes
• Smoking in pregnancy increases the risk of premature delivery and stillbirth. Maternal smoking postpartum is associated with a threefold increase in the risk of sudden infant death syndrome
• Smoking prevalence varies significantly between communities and social groups, with pregnant women in more disadvantaged groups being more likely to smoke than in more affluent groups, similarly those aged under 20 being more likely to smoke than those who are older
• Children who grow up with a smoking parent are also more likely to become smokers themselves, further perpetuating the cycle of inequality
• Interventions to help women to quit smoking have been shown to be cost-effective, and stopping smoking early in pregnancy can almost entirely prevent damage to the baby and help prevent additional treatment costs
• Babies born to smoking mothers who quit early in their pregnancy have the same or similar rates of stillbirth, prematurity, low birth weight and small for gestational age, when compared to babies born to non-smoking mothers

The RCM is a member of the Smoking in Pregnancy Challenge Group , working alongside the Royal College of Obstetricians and Gynaecologists , the Royal College of Paediatrics and Child Health , the voluntary sector and academia. It was established in 2012 in response to a challenge from the then Public Health Minister to reduce smoking in pregnancy rates to 6% by 2022. Further information on this ambition can be found in the Tobacco Control Plan .

For more information, read the NICE guidance on stopping smoking in pregnancy . This recommends routine carbon monoxide screening of all pregnant women to assist in identifying smokers and referral for specialist support to quit.

The RCM’s new position statement on  support to quit smoking in pregnancy  sets out some of the actions that are needed to help this to happen. 

Infant Feeding

Breastfeeding is a public health priority. Midwives and maternity support workers have a central role in providing breastfeeding promotion and support.

The RCM recently refreshed and re-launched its position statement on infant feeding .

The NHS Long Term Plan contains a commitment to delivering evidence-based infant feeding programmes in all maternity services and the RCM is supportive of an outcomes-based approach to increase breastfeeding rates in the UK.

Baby Friendly Initiative is a scheme offered by Unicef to maternity units and other public bodies, including universities and local authorities, on a commercial basis, comprising a programme of training and accreditation of standards.

The NHS provides comprehensive advice on breastfeeding and bottle feeding with links to local support groups.

The Baby Feeding Law Group UK is a group of organisations working together to protect infant, young child and maternal health by ending marketing practices which commercialise infant feeding, mislead consumers and threaten breastfeeding. While its aim is to protect breastfeeding, it does not seek to limit the accessibility of safe and appropriate infant formulas for those who need or want them.

The RCM is represented on the committee of  Becoming Breastfeeding Friendly  (BBF) England, which has developed an evidence-based toolkit through highly structured technical and academic collaboration, led by Yale University. This aims to guide countries in assessing their breastfeeding status, and their readiness to scale up.

The RCM is also a member of the Baby Feeding Law Group, which works to strengthen UK baby feeding laws in line with UN recommendations.

The RCM recognises that many factors influence infant feeding decisions and is committed to supporting women’s choices. We will continue to campaign for high-quality services, improved employment rights and societal acceptance to encourage breastfeeding to continue for longer.

Maternal Obesity

The NHS Long Term Plan has a strong focus on obesity and mapping work is underway to identify best practice in weight management services for pregnant women.

Stepping Up to Public Health describes obesity prevention as healthy eating advice that is generally part of a broad-based discussion on healthy lifestyle behaviours.   Clearly there are health promotion opportunities for midwives and maternity support workers in relation to weight, physical exercise and nutrition.

The RCM and Slimming World jointly undertook research amongst midwives which showed some of the barriers and tools required for effective weight management in pregnancy. 

The RCM is a member of the Obesity Health Alliance , which is a coalition of over 40 organisations who have joined together to reduce obesity.

There are currently no UK-specific guidelines on safe weight gain in pregnancy, although there is NICE guidance on weight management before, during and after pregnancy available .

Antenatal and newborn screening

Stepping up to Public Health identified screening as an integral part of midwives' public health role. NICE guidelines apply to the management of screening, as part of routine antenatal care.

Antenatal and newborn screening programmes  offer tests to pregnant women and their babies at various stages of pregnancy and in the newborn period. These include:

• infectious diseases in pregnancy screening programme
• fetal anomaly screening programme (ultrasound)
• newborn bloodspot screening programme

The RCM supports members with an i-learn module on delivering unexpected news in pregnancy which covers the subject of screening .

Other RCM Public Health initiatives

Homelessness.

The RCM has produced guidance for midwives on the Homelessness Reduction Act and the new Duty to Refer . These regulations came into effect on October 1 and apply to all public services, including maternity.

Women accessing midwifery care may be disclosing housing circumstances that put them at risk of homelessness. A referral to the local authority should be made at this early point to prevent, as far as possible, a difficult situation from becoming a crisis. Consent must always be obtained. Scenarios may include women who are ‘sofa surfing’, experiencing rent arrears or domestic abuse. The referral process is not intended to be onerous and the RCM has suggested relevant questions to ask women and a model pathway to use.

Midwives have a unique opportunity to support women and the RCM is working to support midwives. 

Violence Against Women and Girls

Midwives have a duty to support each and every individual who seeks help as a result of violence, treating them with compassion, respect and dignity and referring them on to appropriate support and treatment in the areas of both health and psychological care.

Learn more about the RCM's work to stop Violence Against Women and Girls .

The RCM supports and promotes ad hoc and seasonal campaigns, including Stoptober, flu & whooping cough vaccination, World Breastfeeding Day and the fortification of flour with folic acid.

Public Health resources across the UK

Nhs health scotland.

NHS Health Scotland has a focussed remit for the reduction of health inequalities .  

The range of public health resources on the  Health Scotland website  relating to pregnancy include information about screening, smoking and substance misuse. 

Health Scotland have a number of online learning resources for midwives, designed to help develop their skills in relation to behaviour change approaches, including motivational interviewing techniques and an online hub for leadership in reducing health inequalities.

MCQIC is the maternity part of the Scottish Patient Safety Programme, which has led focussed national improvement work relating to smoking cessation support during pregnancy . 

The Scottish Public Health Observatory

This organisation gathers together key information and data about public health in Scotland .

Getting it right for every child

This is the Scottish Government’s overarching programme of work designed to improve the chances of all children in Scotland, through improving the identification of babies and families that require additional support beyond universal services.

National Babybox Scheme

This Scottish Government Babybox initiative is an example of a national public health strategy with the aim of reducing inequalities at the start of life.

Public Health Wales

Public Health Wales is the national public health agency in Wales and exists to protect and improve health and wellbeing and reduce health inequalities for people in Wales.

Northern Ireland

Public health agency.

The Public Health Agency works with partners in many different sectors, as well as directly with communities, to reduce health inequalities and ensure collective resources are used effectively.

The Northern Ireland Government publish health and well-being information and advice on their website , including guidance on a broad range of subjects, including vaccinations, screening and making healthy lifestyle choices.

• Safety in services
• All-Party Parliamentary Group on Baby Loss

Health Promotion in Realtion to a Midwife Essay

Health promotion- obesity.

The World Health Organisation (WHO) Ottawa Charter defined health promotion as “the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to

Breastfeeding And Long Term Benefits Of Breastfeeding Essay

The immediate and long-term benefits of breastfeeding have been demonstrated. Mothers are encouraged to begin breastfeeding immediately after delivery, however mothers choosing to breastfeed find numerous challenges once returning to work. There are not appropriate accommodations to support nursing mothers in the workplace. Although there are law in place to support accommodations in the workplace these laws are not enforced and therefore it is virtually impossible for mothers to continue to breastfeed as a result of the significant barriers they face to effectively find suitable accommodations in their workplace. There needs to be a standard for enforcing these policies if the goal is to move toward encouraging all mothers to breastfeed throughout the first 6 months of life.

Perineal Massage

Proctor and Renfrew, 2000 identified that midwives should combine evidence with clinical expertise as the area they practice in is constantly evolving, so as well as basing their practice on their own experiences they need to use research to ensure they are providing the best possible up to date information.

The Ideal And The Real Of Breast-Feed

In this article, “The Ideal and the Real of Breast-Feeding” by Jane E. Brody, Brody brings some good points to light. The campaign to exclusively breastfeed for the first six months in today’s society is becoming increasingly prevalent by health care providers, lactation consultants, and other organizations. Brody’s notable outlook on breastfeeding stems from her own personal experiences with her twin boys. The ever increasing numbers of reasons one should breastfeed and how important it is for the health of the child to continue to grow. As the textbook, “How Children Develop” by Robert Siegler, shows it is a natural life source. Mammals use breast milk as a source of nutrition for their young. Humans have become more reliant on formula feeding.

Critique of Systematic Review

Two authors independently evaluated each article for relevant using a predefined set of criteria. Inclusion and exclusion criteria were specified and were appropriate for the review. The researchers were concerned with the effect education and support for the mothers had on the exclusive breastfeeding rates of healthy newborns. Inclusion criteria included randomized controlled trials (RCT) or quasi-experimental trails. The types of articles included are those that discussed interventions through education or support given to the mother prenatal/postnatal, or a combination. All delivery types were included. For

Patient Teaching

I have chosen breastfeeding as my teaching topic for this assignment. The specific clientèle will be the new mother at between 2 and 7 days postpartum, newly discharged from hospital. As a community health nurse working with children and young families, I do initial postpartum visits at home. Breastfeeding is a very complex skill, natural, yet sometimes difficult to do. The client is often overwhelmed with information received in hospital, so sessions must be kept short, and made easy to understand. The area in which I work is multicultural. There is often a language barrier which further complicates

Sharon Gough's Lactation Nurse: A Case Study

Sharon initially found it difficult to teach nurses about the normalcy of breastfeeding and why infants do not need formula in the first few days of life. Sharon often struggles with convincing women that their body made colostrum during pregnancy and that it is enough to feed their baby. Changing old ways and convincing mothers that breastfeeding is the perfect food for their babies is sometimes challenging. However, Sharon continues to do what she does because she knows that breastfeeding is the best for babies and if she doesn’t do her job, who else will?

Postpartum Mothers

One of the biggest decisions for a new mom is whether or not she will breast feed her newborn. This decision will not only impact the mother but it will also have many great affects on the baby. In the media we only see advertisements about formula which costs more money and is artificial. Why is it that the most natural source of food for our baby’s does not have the same kind of attention, if not more? Nurses need to help spread the awareness of the major differences between formula and breastfeeding to help higher the rates of breastfeeding, The purpose of this paper is to discuss how nurses can help to promote healthy breastfeeding to postpartum moms through three main roles which are, providing research that confirms the benefits of breastfeeding,

Developing Breastfeeding Practices In Health Care

Various researches exists in the health care premises to determine the best policies that will promote the utilization of resources within healthcare. However, some research work that utilizes social scientific methods fails to focus on exploring maternal ambiguity and ambivalence. Rather, the paradigm informing the majority research about infants feeding practices remains a public health perspective. From that perspective, many studies tend to explore why women do not initiate breastfeeding. Again, it suggests some options why women do not breastfeed for the recommended period. Thus, it is imperative to recommend the appropriate interventions to change maternal behaviour. The work remains the most accurately considered advocacy research as its purposes help the overall public in some ways. It gives additional weight to arguments for devoting more governmental resources to breastfeeding promotion. A small number of studies have utilized social sciences methods to generate valuable insights about the tension between policy and maternal practices and experience.

Breast-Feeding Vs. Bottle Feeding Is A Very Important Decision

Breast-feeding vs. bottle feeding is a very important decision for new parents as well as a very hot topic of debate for most heath oriented communities. Most health, family and infant related communities and services such as the American Academy of Pediatrics, American Medical Association, the World Health Organization, etc. support and promote breast-feeding infants. Their suggestion urges mothers to at least breastfeed for the first few days after giving birth even if they decide to bottle feed their infant(s), so that the infant(s) can get the health benefits from the mother 's milk and also so that the mother can alleviate some of the pressure in her breasts from the milk production. Cost wise breast-feeding is more cost efficient

Health Promotion. This Paper Will Discuss The Health Promotion

The World Health Organisation (1986) defines health promotion as “a process of enabling people to have control over the determinants of their health in order to achieve physical, mental and social well-being”. Health promotion covers a broad spectrum of activities, all working towards achieving positive health and wellbeing of individuals, groups, and communities (Gates & Barr, 2009) . Health promotion encompasses

Breastfeeding Vs Bottle Feeding

During pregnancy, mothers are often faced with the personal decision of whether they should breastfeed or formula-feed their newborn. This paper discusses the advantages and disadvantages of each feeding method. The purpose of this paper is not to shame a mother for the feeding method she chooses, but instead to provide understanding into the reasons why a mother may choose breastfeeding over formula-feeding. A commonly asked question is: “Is breast really best?” There is no right or wrong choice, just the best choice for mom and baby.

To Breast Feed or Not to Breastfeed

• 7 Works Cited

Throughout this paper, the author information will provide information on how different methods of teaching can help to influence the continuation of breastfeeding in pregnant and postpartum mothers. The paper will also critique three research articles. The articles will consist of either qualitative or quantitative research. The main goal or purpose of this paper is to show why mothers discontinue breastfeeding after discharge and how healthcare providers can more appropriately promote its continuation to these mothers.

Baby-Friendly Initiative

Many studies were done to identify the effectiveness of the Baby-friendly Initiative practise around the world. One of the research shows that 87.3 % to 89% of mothers are breastfeeding and the Baby-friendly Initiative has reached the highest rate in Canada, BC

Breastfeeding Vs Formula Feeding Case Study

All mothers have a choice in how they decide to raise their family. In the hospital, the health care team is supposed to be there in support to protect and to educate their patient, help them in identifying their rights, and educating them with proper and abundant information. The dilemma I am exploring specifically relates to the postpartum floor at Kaiser Walnut Creek, which is the idea of breastfeeding versus formula feeding. According to Healthy People 2020 as cited by the Centers for Disease Control and Prevention, in 2011, 81.9% of mothers breast-fed during the early postpartum period, 60.6% until 6 months, and 34.1% until 12 months. In addition to the increasing rate of breast-feeding, there are many benefits for the newborn, as well as the mother. The newborn will have passive immunity against infections, decreased rate of sudden infant death syndrome, reduced risk of allergies and asthma, and decreased incidence of diabetes mellitus and obesity later in the future. The mother will have easier postpartum weight loss and lessens bleeding, delayed fertility, and reduced risk of breast and ovarian cancer. In addition, breast-feeding is convenient and cost effective (Ladewig,

Related Topics

• Breastfeeding
• Public health
• Health economics

Certified Nurse Midwife Career Overview

NurseJournal Staff

Contributing Writer

Learn about our editorial process .

Updated May 15, 2023

Reviewed by

Nicole Galan

Contributing Reviewer

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A CNM provides care throughout pregnancy, birth, and beyond. Discover more about how to become a certified nurse midwife and employment prospects for CNMs.

Are you ready to earn your online nursing degree?

What does a certified nurse midwife do.

CNMs work in a variety of practice settings including hospitals, community clinics, and birthing centers. While their primary role centers on women's healthcare during pregnancy, birth, and the postpartum period, CNMs provide primary care, gynecological care, and family planning services for women throughout their reproductive years and menopause. Some CNM responsibilities are listed below:

Primary Responsibilities

• Provide prenatal, delivery, and postnatal care to women and monitor newborns
• Offer assessment, diagnosis, and treatment
• Treat both males and females for sexually transmitted diseases
• Offer education and counseling in health promotion and disease prevention

Skills Learned

• Patient care for all aspects of pregnancy, labor, and delivery
• Communication and leadership skills
• Technological proficiency
• Patience and compassion

Credit: SDI Productions / E+ / Getty Images

Where Do Certified Nurse Midwives Work?

This list describes the various roles performed by CNMs in some of the most common workplace settings.

These CNMs work with obstetricians handling vaginal and surgical births. They assist with pain management and provide personal care to pregnant women and infants.

Birthing Centers

These CNMs diagnose and treat gynecological conditions and monitor women during pregnancy. They may offer family planning and contraception counseling and treat sexually transmitted diseases.

Public Health Clinics

How is a certified nurse midwife different from a direct-entry midwife or a traditional midwife.

A CNM must hold a graduate midwifery degree, a valid registered nurse (RN) license, and certification through the American Midwifery Certification Board (AMCB). This certification qualifies them to apply for licensure in any of the 50 states.

The direct-entry midwife designation includes both certified midwives (CMs) and certified professional midwives (CPMs). Unlike CNMs, direct-entry midwives may obtain certification without first becoming licensed nurses. While CMs may enter the field without nursing training, not all states allow them to practice. Most direct-entry midwives hold the CPM credential — the only certification that provides training for out-of-hospital deliveries.

Traditional midwives lack formal nursing education but have acquired training through direct experience. These unlicensed midwives, typically working with poor and/or rural populations, rely on their experience, knowledge of traditional (or folk) medicine, and the trust of the communities they serve. However, they might not have a legal right to practice midwifery, though this will depend on the state where they live and/or practice.

How to Become a Certified Nurse Midwife

CNMs must earn both undergraduate and graduate degrees to become a certified nurse midwife , acquire an RN license, and get national certification and licensure in the state where they intend to practice.

Graduate with a bachelor of science in nursing (BSN).

Pass the nclex-rn exam to receive rn licensure., apply to an accredited master’s or doctoral midwifery program., graduate with your master of science in nursing (msn) or doctor of nursing practice (dnp) in midwifery., pass the amcb exam., featured online programs, how much do certified nurse midwives make.

The average annual nurse midwife salary , as of May 2022, was $122,450. The BLS projects the demand for nurse midwives to grow by 7% between 2021 and 2031. CNMs can expect the highest salaries in major metropolitan areas, where they earn annual average salaries ranging from $191,470 in San Francisco, CA, to $169,190 in Los Angeles, CA.

Several factors contribute to this favorable employment outlook. Hospitals and clinics hire nurse midwives to handle low-risk pregnancies and assist in nonsurgical births to lower costs and reduce complications. The demand for midwives has also grown as more women choose natural childbirth and birth center options.

Frequently Asked Questions About Certified Nurse Midwives

Do nurse midwives deliver babies.

CNMs who typically work with pregnant individuals experiencing low-risk pregnancies may deliver babies in hospital and out-of-hospital settings such as home births and birthing centers. Nurse midwives do not induce labor and try to avoid pain medication during the birthing process. In hospital settings, they assist obstetrics and gynaecology (OB-GYN) doctors who manage both low-risk and high-risk pregnancies.

What are the benefits of earning a doctorate for nurse midwives?

The nursing profession has begun to advocate for the DNP as the terminal degree for advanced practice nurses, including nurse midwives. Earning a DNP not only enhances career prospects in administrative and educational roles but also boosts salary. The nursing field recognizes the relationship between doctoral-level training and improved healthcare delivery, quality, and safety.

How long does it take to become a certified nurse midwife?

BSN graduates may earn a master's in two years or less or a BSN-DNP in approximately 3-4 years. Those entering the field with only an RN can choose RN-to-MSN or RN-to-DNP programs that may take longer. Direct-entry programs for students with non-nursing undergraduate degrees may require between 2-4 years of study, including prerequisites and clinical requirements.

What skills are important for nurse midwives?

Nurse midwives acquire specialized nursing and technological training in reproductive and gynecological healthcare and the skills needed to provide primary care through pregnancy and childbirth. CNMs also need "soft skills" to work with diverse populations, or the ability to function in high-stress situations, strong communication skills, leadership qualities, and a caring and compassionate approach to patient care.

Resources for Certified Nurse Midwives

American college of nurse-midwives, midwives alliance north america, american midwifery certification board, association of women's health, obstetric and neonatal nurses, related pages.

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Birth Stories and Birth Blogs

• Resolving Birth Issues
• Complaining About Your Care

Subsections on this page:

Online video birth stories, midwife blogs, birth blogs, print publications, homebirth stories, waterbirth stories, unassisted birth stories, cesarean/vbac stories, general birth stories, collections of birth stories on other sites.

This is a collection of birth stories from a number of different distribution lists.

These stories are included here so that caregivers can get a better sense of the tremendous power they hold - for good or evil. Attending birth is a sacred trust, and compromising client care out of ignorance, inexperience, fear or selfishness is a sacrilege. Each of us has a responsibility to serve each and every woman, baby and family to the best of our abilities, and if our abilities aren't up to the task, we'd better improve them or refer.

Some stories include details of a triumphant birth, some are horror stories. I've tried to title them in a descriptive fashion so that pregnant women aren't exposed to horror stories they would rather avoid.

Naitre_enchantee - "Enchanted Birth" - beautiful, birth using low toning and vibrations.  I wish our midwife-attended births in the US could be this hands-off, but our licensing requirements make us "offer"/impose frequent monitoring (every 2-5 minutes during pushing) of the baby's heart tones.  Still, we can have similar births, except for the monitoring.

The Midwife Next Door - A blog discussing midwifery, normal birth, and modern obstetrics - from birthsense.org

Women in Charge - Blog of Maria Iorillo, a homebirth midwife in San Francisco.  She also has links to other birth blogs.

20 Years of Birth Stories - Barbara Hernadez, California midwife

Have a Natural Childbirth - This blog is created by a coalition of doulas, midwives and other natural childbirth advocates to help you explore and discover the joys of natural childbirth

Stuff Birth Junkies Like - Here is the place where you are invited to post comments on anything physical, spiritual, or emotional that you love about birth, birthing, attending birth and beyond.

You can also look for midwifery blogs on Blog Talk Radio , the worlds largest social radio network. Create your own internet radio show. Listen to thousands internet radio shows and podcasts live each day.

Motherhood Matters - Insight into matters of motherhood and thoughts about why motherhood matters.

Jacquie Munro is a doula in Vancouver, British Columbia, Canada - Her birth blog will remind you of everything that's right about birth!

PTSD After Childbirth Blog by Jodi Kluchar

If you have an inspirational birth story to share, consider submitting it to some of these print publications, in addition to web sites:

Fit Pregnancy : They pay $300.  Their focus is overcoming challenges.  It is great if you can tie in a health and fitness related aspect.

Pregnancy magazine

Collections

Homebirth Birth Stories from childbirth.org

Unassisted Birth Stories - a collection from Bornfree - The Unassisted Childbirth Page

You can download short video clips of different "kinds" of births here, including a homebirth and waterbirth.  I'm weeping....  :-)

And now for something completely different . . . The Birth of Grey Forest Walt ~ an outdoor birth

The Midwife's Journal - by Joy Johnston.  This is a terrific collection of musings from the midwife's point of view.

How Homebirth Mom Handled Long Pushing Stage

A Midwife's Apprentice Tells Her Birth Story

Matthew's Birth Story - A Homebirth after Two Hospital Births

Homebirth Transport for Section - Felt Betrayed by Midwife

Homebirth Testimonies - (A collection of letters from homebirth parents to their midwife.)

Being Born Blessed (born in the rain) -by Leilah McCracken - this birth fantasy is based on Leilah's personal birthing experience, and she does a wonderful job of articulating the joy that is inherent in birth.

Waterbirth Stories - a collection from Karil Daniels' Waterbirth Website .  You may also want to check out the Waterbirth Photo Gallery .

Waterbirth Birth Stories from Waterbirth International .

A Semi-Unassisted Waterbirth - My favorite waterbirth story - this mama is so strong!

The Water Birth, Starring Tom Digby Simpson - this is a very nice summary of  a labor, birth and immediate postpartum, with a nice timeline and comments from the birth attendants.

Nikelle's Story - As Told from a Mother's Heart - great photos!

Waterbirth of Ten-Pound Baby with No Tears - Great description of the feelings of transition, and an account of the use of the Gaskin Maneuver to resolve shoulder dystocia.

Waterbirth with lots of great pictures

A Home Waterbirth with Sibling

Waterbirth of 12-Pound Baby

OK First Birth and Dream Waterbirth for Second Birth

Taren's Home Waterbirth

Childbirth-Natures Way

Waterbirth Birth Stories

See also: Unassisted Childbirth

Unassisted Childbirth & Pregnancy Australia from purebirth-australia.com

homebirth.org.uk has quite a few unassisted birth stories

A Picture of Faith, Love, Trust, Blood, and VICTORY -by Katie Scribner  [Ed: birthlove.com is not available at this time.]

Awakening By Bethany Fitzpatrick - This is an amazing personal essay about the experience of a mother's developing a relationship with her baby/becoming a mother after a cesarean birth. The focus is not on the mechanics of the birth or even how this mother got to that point in her birth journey - it's about being in the moment with herself and her baby in the aftermath.

C-section, VBAC, HBAC . . . Ecstasy? - "I believe  that our increasingly joyous birth experiences have been a real blessing to him and to us as a couple. "

Laura and Mike Write about Homebirth After Two Cesareans

Anita Plans Homebirth after A Cesarean And a Horrible VBAC

War Story - Cesarean Poetry (Angry)

Poetry about Anguish from Cesarean

Kristi - Our Miracle Baby - Mom Ignores Medical Advice to Abort A Troubled Pregnancy and Births a Healthy Baby.  Kristi was also one of the first babies born naturally to a mother with multiple previous cesareans.

VBAC Success - Story and Rates

Jenny's Tale - Saga of a Birth Gone Wrong or Yes, It Can Happen To You

Jenny Strikes Back - A Set of Letters and a Meeting about the Unnecessary Cesarean

Horrible First Birth and Dream VBAC for Second Birth

Two Unnecessary Cesareans

Mom with Previous Myomectomy Declines Unnecessary Cesarean

Paralyzed woman watches helplessly as her unborn baby is surgically removed!

Unnecessary Cesarean with General Anesthesia resulting in severe postpartum depression

Eight Hours of Torture - Horrible Epidural Experience Ends in Cesarean

Traumatic scheduled c-section for breech...VERY LONG!!!

Marriage Problems after Cesarean

Telling Husband About Anger from Cesarean

The Pain Continues - How A Cesarean Birth Can Affect a Marriage

VBAC After 3 Cesareans

Donna Young ( Protect Babies web site ) and two other mothers have shared their birth stories in a peer-reviewed medical journal, Medical Veritas . Contact Donna for a copy.

Three Births - Hospital, Birth Center, and Home - a dad writes about his children's births.

Face Presentation with Mentum Posterior

A Nice Hospital Birth Followed by Two Fabulous Homebirths - by Sheryl Wright in New Zealand

Comments on Personal Births

Be Prepared for a Cesarean

Punishing Treatment

Four Posterior Births - Plans Next One As Waterbirth

Horrible Birth for Very Young Woman

Very sad story of maternal death from Pre-Eclampsia - Dad Blames Teaching Hospital for Gross Neglect and Condemns U.S. Medical System

Homebirth After Birth Center

Unhindered Birth

The Radical Fringe Mothering Page Wonderfully supportive Web page written by a woman who was transformed by her birthing experiences. It includes her two beautiful birth stories.

First Birth in the Hospital, Second Birth At Home

Forceps, C-Section, VBAC, Homebirth

Thoughts Approaching Birth

Stress Approaching Birth

Importance of Husband's Support

Another Story on the Importance of Husband's Support

General Anesthesia Horror Story

Attending Best Friend's Horror Birth - Coincidentally Face Presentation

Posterior Birth Story

Second Birth Helped Heal from Trauma of First Birth

Hospital Disregarded Wishes

Many pregnant women cannot get enough of other women's birth stories. Although we are not expanding this site, I encourage you to visit these other sites and contribute your birth stories as appropriate.

Positive Birth Stories - Reclaiming birth, story by story

TrufeLife Pregnancy Stories from pregnancycorner.com

Birth Stories from Lisa Bobrow's site

Ways of birthing and birth stories at Women of Spirit

Birth Story Diaries:  real births, real pictures

Babies Online Birth Announcements There is no faster way to introduce your new baby to the world than the internet.  Babies Online provides proud parents with the opportunity to announce the birth of their newborns on the WWW by creating their very own web page -- AND IT'S FREE!!

Birth Stories -  This is a site full of birth stories. There are over one hundred birth stories on it now. Very diverse. Hospital births, birthing center births, home births and even a car birth! Some later updates on the kids. You can also add your own birth story.

ParentsPlace.com - a very large collection

Labor of Love Birth Stories

Homebirth Stories - a collection from kjsl.com

Another collection of Unassisted Birth Stories from Holistic Health and Life's Pregnancy Pages

Robin Elise Weiss' pages - Birth Stories

Birth Stories from The Revolutionary Passion of Mothering [Ed: birthlove.com is not available at this time.]

Natural Birth Stories WebRing

Birth Stories Webring

Ananda Lowe is collecting stories about "long" but healthy second stage (pushing) -

You can also submit your birth stories (either as a mom or as a midwife to Midwifery Today - [email protected]. You may want to read their submission guidelines .  

SEARCH gentlebirth.org

Main index page of the midwife archives, main page of gentlebirth.org          mirror site, please e-mail feedback about errors of fact, spelling, grammar or semantics. thank you..