Asthma is one of the most common potentially serious conditions that complicates pregnancy, with approximately 3–14% of pregnant women affected by asthma worldwide; 12.7% of pregnant women in Australia and 8.3–10.9% in the UK (Sawicki et al, 2011; Charlton et al, 2013). Evidence emerging in the literature demonstrates that if asthma is well-managed throughout pregnancy, adverse maternal and fetal outcomes such as maternal hypertension, preterm birth and low infant birth weight can be reduced (Schatz et al, 1995; Murphy et al, 2006; Murphy et al, 2011). The clinical course of asthma during pregnancy is unpredictable, making management challenging (Kircher et al, 2002). The goal of effective asthma management during pregnancy is the prevention of exacerbations, which can cause hypoxic episodes in the mother and reduce oxygen to the baby.
In Australia, the recommended management of asthma during pregnancy is outlined in the guidelines developed by the National Asthma Education and Prevention Program (NAEPP) (National Heart Lung and Blood Institute, 2007). The National Asthma Council Australia (NAC) (2014) has also produced evidence-based guidelines addressing antenatal asthma management. All current asthma management guidelines recommend a holistic and collaborative approach to management, suggesting cooperation between all health professionals involved in the pregnant woman's care. Pregnant women with asthma should be offered regular asthma review every 4–6 weeks, which includes peak expiratory flow monitoring. Pharmacological treatment of asthma should be the same as treatment for the non-pregnant woman, and women should be educated to minimise exposure to their asthma triggers and seek prompt management of exacerbations during pregnancy (NAEPP, 2007; NAC, 2014).
Despite the guidelines stating that all health professionals involved in the pregnant woman's care should provide antenatal asthma management, provision of antenatal asthma management by midwives has not previously been studied. Lim et al (2014) examined a multidisciplinary approach to the management of maternal asthma in Australia, but focused on management by GPs, pharmacists and asthma educators. Other public health issues have been examined in relation to midwives' provision of antenatal management, including provision of listeria education (Bodarianzadeh et al, 2011) and oral health education (George et al, 2011). Both of these qualitative studies identified barriers such as time constraints, lack of knowledge of the health issue and lack of clear referral pathways. Similar barriers were identified in studies exploring perinatal mental health (Ross-Davie et al, 2006) and examination of the newborn (Rogers et al, 2003). Although these studies were undertaken in the UK, common barriers to midwifery management of these issues including lack of knowledge, training and confidence to address the health issue at hand and time constraints were identified.
The importance of effective antenatal asthma management for the mother and baby and the identified dearth of knowledge addressing the antenatal asthma management by midwives prompted this research to examine midwives' knowledge about asthma in pregnancy and their perceived role in antenatal asthma management.
Aim
The aim of this paper is to report midwives' perceived barriers to the provision of asthma management for pregnant women.
Method
A qualitative descriptive design was used. This methodology was selected to gain firsthand knowledge about the topic from midwives. Qualitative description is useful in obtaining straightforward answers to questions which may be relevant to policy makers and practitioners (Sandelowski, 2000; Neergaard et al, 2009).
The study setting was the antenatal clinic in a large tertiary referral public hospital in regional New South Wales, Australia. In order to gain in-depth information regarding antenatal asthma management by midwives in the clinical setting, a purposive maximum variation sampling technique was used. This sampling technique ensured midwives who had any level of first-hand experience providing antenatal care to women with asthma were recruited.
Data collection
Data collection occurred over a 6 month period in 2012, through a series of individual in-depth, semi-structured interviews with a total of 13 consenting participants. Field notes were also taken during the interviews. Data were de-identified using numbers rather than participants' names. The interviews were digitally recorded and transcribed and returned to the participants for member-checking to confirm transcript accuracy.
Data analysis
The data analysis process used was the four-stage process described by Morse and Field (1996) (Table 1). This is not a linear process but one whereby the researcher is immersed in the data and continually works through the stages of the process in order to maximise understanding of the data.
| 1. Comprehending | ‘Making sense of the data’, listening to the audio recordings, reading and re-reading the written transcripts and reflecting on field notes |
| 2. Synthesising | The ‘sifting’ phase of the process. Data further explored and recurrent words and comments noted |
| 3. Theorising | Identification of the patterns and relationships between the words and comments and the development of categories and sub-categories emergent from the data |
| 4. Recontextualising | The development of emergent categories and sub-categories and the consideration of these in the context of established knowledge |
Strategies employed to ensure rigour included adopting a well-established research method; documenting an audit trail; providing a rich description of the study setting in order to determine the possibility of transferability; using quotes from interviews to illustrate that the research findings were grounded in the data and peer review of analyses.
Ethical approval
Ethics approval was granted for this project by the Hunter New England Area Health Service Human Research Ethics Committee (HREC) (11/12.14/5.08) and the University of Newcastle HREC (H-2012-0030).
Results
Overall the findings of this study were categorised into four main categories and 12 sub-categories (Figure 1). A major finding was the identification of barriers to the provision of asthma management. Participants appeared quite animated when discussing the barriers they felt existed. Five sub-categories of the main category of barriers were identified and will be the focus of this paper. Additional findings will be reported in other publications.
Barriers to asthma management
During the semi-structured interview process, participants were asked, ‘What barriers, if any, do you feel exist that may prevent optimal antenatal asthma management occurring?’ When responding to this question many participants discussed issues such as time constraints, midwives' and pregnant women's knowledge about asthma in pregnancy and the lack of a clear referral pathway for women identified as requiring asthma management. Lack of knowledge about asthma in pregnancy emerged as a significant barrier to midwives providing antenatal asthma management.
Lack of knowledge about asthma in pregnancy
A general lack of knowledge about asthma in pregnancy was reported by many participants, with some stating:
‘I know very little.’ (Participants 1, 4 and 11)
‘I don't know a lot at all.’ (Participant 9)
‘I don't know enough about it [asthma] to manage it … it's difficult to educate when you don't know that you are telling the right thing.’ (Participant 4)
Participant 8 responded to the prompt about barriers to providing antenatal asthma management by stating:
‘Yeah, a lack of knowledge, yeah! … a lack of knowledge about it [asthma] … when they [the pregnant women with asthma] do come through [the antenatal clinic] often we [the midwives] send them off to other people that are cleverer and know far more about it [asthma].’ (Participant 8)
Some participants also mentioned lack of education and felt that this contributed to their lack of knowledge and their subsequent inability to provide adequate antenatal asthma management:
‘I don't feel that we're qualified … I think we probably need a bit more education and we could certainly include it [asthma management] into our care.’ (Participant 10)
Time constraints
When discussing lack of knowledge about asthma in pregnancy, participants also discussed how time constraints affected their ability to improve their knowledge of this health issue.
Many participants mentioned the issue of time. When discussing the need for further education in regard to asthma in pregnancy, many commented on the inability to obtain such education due to time constraints:
‘We are supposed to keep on top of stuff [through education] but when do you get the time and when can you afford to have it?’ (Participant 5)
‘It is our role to educate women in regards to all aspects of their pregnancy and asthma but as with every other area of education it's having the staff to do it and having the time to do it.’ (Participant 4)
‘It's about having the time to educate yourself … you don't get much time or money to educate yourself.’ (Participant 5)
Time was also suggested as a barrier to the midwives completing a thorough medical history on the women. Participants made comments such as:
‘Time constraints would probably be the biggest issue, we don't have a lot of time to talk about much, so generally it's concentrated just on the pregnancy.’ (Participant 11)
‘We don't get time to look at that specific area [asthma].’ (Participant 10)
It was suggested that rushed antenatal visits may lead to decreased identification of asthma, especially if the pregnant woman does not mention it.
Pregnant women's knowledge about asthma
Failure for women to recognise asthma as a potential problem during pregnancy, was another barrier identified by some participants. It was suggested that some women:
‘Take it [asthma] very lightly’ (Participant 3).
Participant 12 identified that asthma is a chronic illness and suggested that some women:
‘Just think that [asthma symptoms] are normal for them.’ (Participant 12)
‘[Some pregnant women] don't put an emphasis or importance on it [asthma] in their pregnancy … it's the last thing that they are thinking about unless they have had a major problem with it in the past.’ (Participant 10)
Participant 3 commented that she felt asthma was a priority but:
‘The woman has a different idea … it just seems that if you have a chronic illness it's not regarded as a health affliction and they do survive with it well.’ (Participant 3)
Participants appeared frustrated by the lack of concern shown by some women in regard to their asthma management during pregnancy and how to help with their asthma management if asthma was identified.
Lack of a clear referral pathway
A general sense of frustration and confusion was evident from the participants when discussing the topic of a referral pathway. Participants stated that there was not a clear referral pathway and that this was a definite barrier to being able to provide adequate care for pregnant women with asthma:
‘No, I don't think there is a referral pathway … that's major … a major problem when it comes to asthma and pregnancy and even just identifying what your next step would be … who do I refer to? … How do I refer to them?’ (Participant 4)
Other participants had some suggestions as to who to refer to. Participant 13 suggested that she would refer women back to their GP:
‘For GP management and to have an asthma plan made for their pregnancy.’ (Participant 13)
Participant 12 suggested that she would:
‘Get them [the women] to go and see their GP and make it a matter of priority for them.’ (Participant 12)
Other participants stated that they would
‘Get her [the woman] to see a consultant or get her referred onto the respiratory people so they can link her up to have some sort of asthma management plan.’ (Participant 8)
‘Get them [the women] to see one of the registrars or obstetricians and then they would refer them on I guess.’ (Participant 2)
Overall there was no evidence of a clear referral pathway at this service and many participants felt that this would help them to provide better antenatal asthma management.
Lack of accessible asthma management equipment
One other barrier identified by two participants was that of a lack of available equipment to treat an exacerbation of asthma. Participant 1 stated that treatment of any exacerbation of asthma:
‘Is very difficult in the delivery suite setting … we don't have all the equipment to treat the exacerbation of asthma … even down to a spacer.’ (Participant 1)
When recalling a clinical scenario, Participant 3 also commented that:
‘Delivery suite didn't have much equipment to deal with asthma: spirometry, etc.’ (Participant 3)
Discussion
Barriers to providing optimal antenatal asthma management such as, time constraints; pregnant women's knowledge about asthma in pregnancy; midwives' lack of knowledge about asthma in pregnancy; lack of accessible asthma management equipment and the lack of an up-to-date referral pathway were identified. These were consistent with previous research examining the midwives' role in providing health promotion during pregnancy (Rogers et al, 2003; Ross-Davie et al, 2006; Gharaibeh et al, 2010).
Time constraints were reported by all current study participants to be a major barrier to the provision of adequate asthma care. Participants did not have time to obtain an adequate health history initially, and did not have time to educate themselves when a deficit was noted, such as a lack of knowledge about asthma in pregnancy. Participants felt that staff shortages and an increase in the number of women the midwives were seeing on a daily basis contributed to this. Time constraints are noted as a barrier in other studies examining health issues being addressed in the antenatal period.
Varying knowledge about asthma in pregnancy and a perceived lack of concern about asthma in pregnancy by some pregnant women was also an identified barrier for midwives. Participants felt that some pregnant women did not see asthma as a priority during their pregnancy unless they were experiencing an exacerbation of symptoms and some women were reluctant to seek or accept advice from midwives, choosing instead to acknowledge the advice given by their GP or respiratory specialist. The pregnant woman's lack of confidence in the midwife providing such information may be related to the midwives' lack of knowledge about asthma in pregnancy, which participants felt contributed to a lack of confidence in providing asthma education and advice. Other studies found that midwives identified a knowledge deficit when asked to provide education on other important issues during pregnancy, including oral health, listeria education, smoking cessation, genetic counselling and antenatal depression (McLeod et al, 2003; Ross-Davie et al, 2006; Gharaibeh et al, 2010; Bondarianzadeh et al, 2011; George et al, 2011). Brodie (2006) commented on the inability of midwives to access ongoing education, especially in rural and remote areas due to geographical isolation and limited access to funded support. This lack of knowledge, therefore, influenced the role the midwives felt they could play in the antenatal management of health issues such as asthma. The role of the midwife in antenatal asthma management will be further addressed in subsequent publications.
The lack of a clear referral pathway was identified by the majority of participants in this study as a barrier to the provision of adequate antenatal asthma management. If a pregnant woman was identified as having asthma and requiring further asthma management, midwives were unsure to whom they should refer the woman. There was a general lack of confidence in the referral system and no clear pathway for referral. Studies by Bondarianzadeh et al (2011) and George et al (2011) also report that midwives question which health professional would be appropriate for the health issue being identified and request a clear referral pathway.
The provision of accessible asthma management equipment was also identified as a possible barrier to providing adequate antenatal asthma management. Participants who had the confidence to manage an asthma exacerbation did not have the necessary equipment available to do so.
Implications for education
To address these identified barriers, education programmes that stress asthma as a significant public health issue need to be developed. These programmes need to be directed towards all health professionals involved in antenatal asthma management but particularly tailored for midwives and student midwives. Concentrating on midwifery education can maximise the contribution of midwifery in addressing public health issues such as asthma.
Better use of current resources should also be examined. Information pamphlets produced by the Asthma Foundation of New South Wales (2006) are available to health professionals and pregnant women and provide evidence-based information regarding the management of asthma during pregnancy. The Australian Asthma Handbook produced by the National Asthma Council (NAC) (2014) is available online with unrestricted access and outlines recommended advice to be given to pregnant women with asthma.
Implications for clinical practice
The need for the development of a clear referral pathway for women with asthma in pregnancy was identified in this study. A referral pathway should be developed in consultation with all stakeholders associated with pregnant women's care, including the pregnant woman, midwife, GP, obstetrician, respiratory specialist and management teams in the institution where the pathway was to be implemented. Developing and implementing a referral pathway for antenatal asthma management may result in significant clinical practice change. Consequently, midwives may experience less confusion about referral of women with asthma and experience more confidence in the referral process and their ability to provide adequate care to women with asthma. A clear referral pathway would contribute to providing a more organised and uniform approach to women's antenatal asthma management while still acknowledging individual needs and variances.
Time constraints are difficult to address. One solution may be to examine the time midwives have to spend with pregnant women antenatally and how this can be better managed to accommodate woman-centred care and the ability to address health issues thtat arise in pregnancy. Medical history questions could be mailed to women when they are offered a ‘booking in’ appointment. These questions could be answered in advance, highlighting issues women feel need to be addressed during their pregnancy. This would empower women to be active participants in their antenatal care, as well as freeing up time for midwives.
Provision of accessible asthma management equipment is a relatively simple solution to an identified barrier. As a result of this study, asthma exacerbation packs including a spirometer, spacer and salbutamol inhaler have been made available in the units of the tertiary referral hospital where this study was conducted.
Implications for future research
An effective education programme and clinical referral pathway that could be implemented into various institutions and models of care to improve antenatal asthma management needs to be developed. Evaluation of the implementation of such interventions would add to the body of evidence which currently examines the impact of interventions associated with health issues such as asthma in pregnancy, on maternal and fetal wellbeing.
The Australian Institute of Health and Welfare: Australian Centre for Asthma Monitoring (2013) found that there is no nationally consistent collection of asthma management data from pregnant women. With improved information about management practices for pregnant women with asthma, it may be ascertained who is receiving adequate antenatal asthma management and opportunities for improvements. Improving data collection about antenatal asthma management by augmenting existing national perinatal data, conducting periodic surveys in the antenatal setting and enhancing general practice data may contribute to the identification of additional problems and solutions regarding antenatal asthma management and have flow-on effects for other public health issues affecting pregnancy.
Study limitations
The sample size for this study was small and participants were recruited from a single health care facility. Recruitment ceased once data saturation was confirmed. The results may not be transferable beyond this group, however, they are potentially transferable to similar settings.
Study strengths
This is the first study to examine the knowledge midwives have about asthma in pregnancy and their perceived role in antenatal asthma management. New knowledge about barriers to midwives providing antenatal asthma management was identified, which could be addressed by conducting further research and by developing, implementing and evaluating education and referral resources in the clinical setting. The use of a maximum variation sampling approach ensured all midwives providing antenatal care across a range of practice settings within this institution were given the opportunity to participate, broadening the perspective from which data were collected. Rigour was maintained via member-checking, peer review and a documented audit trail.
Conclusion
Barriers exist that prevent midwives from providing recommended antenatal asthma management. These barriers include lack of knowledge about asthma in pregnancy; time constraints and lack of a clear referral pathway. Developing and implementing asthma education for midwives, and a referral pathway for pregnant women with asthma would address these barriers. This has the potential to improve antenatal asthma management, leading to better maternal and fetal outcomes, and improved confidence for midwives.