Birth is a highly emotive experience. For many women, ‘it is a profoundly life-affirming experience, with the potential for long-term positive effects for the mother, baby and family, emotionally, psychologically, neurobiologically, and socially’ (Lynch, 2020). At the other extreme, it can be a devastating experience affecting every aspect of ‘self ’ for many years. It can have short- and long-term implications for maternal and infant wellbeing (Thompson and Feeley, 2019). Rites of passage, particularly in the first birth, change a mother (and her father/partner) fundamentally in terms of the social role that they will adopt, and for the woman, has the potential to affect every aspect of her health (Downe and Finlayson, 2016).
Normal straightforward childbirth for low-risk women is widely evidenced to confer the most beneficial physiological and biosocial outcomes for mothers and babies, when compared to technological childbirth (Buckley and Uvnas Moberg, 2019). It follows then that the decisions made during childbirth can greatly affect a woman's experience of labour and birth and subsequent health and wellbeing.
Philosophical views of childbirth
The philosophical world views of childbirth are often described in quite starkly opposing terms. The technocratic or biomedical model is one side and the social or midwifery model of childbirth is the other. These models are outlined in Table 1.
Table 1. Medical model and social/midwifery model of childbirth
| Medical model | Social/midwifery model |
|---|---|
| Doctor centred | Woman centred |
| Objective | Subjective |
| Body mind dualism | Holistic |
| Pregnancy and childbirth: only normal in retrospect | Pregnancy and childbirth: normal physiological process |
| Statistical/biological approach | Individual psycho-social approach |
| Biomedical focus | Psycho-social focus |
| Medical knowledge is exclusionary | Knowledge is not exclusionary |
| Intervention | Observation |
| Public | Private |
| Outcome: aims at live, healthy mother and baby | Outcome: aims at live, healthy mother and baby and satisfaction of individual needs of mother/couple |
| Control and subjugate | Respect and empower |
| Homogenisation | Celebrate difference |
| Technology as master | Technology as servant |
| Evidence | Intuition |
| Safety | Self-actualisation |
In a social model, childbirth is physiological, with the inherent expectation that it will be a safe and satisfying experience. It is based on holism, not just on biophysical processes, and embraces innate intuitive forces emanating from within women themselves (Walsh, 2017). In a technocratic/biomedical model, childbirth is pathological and risky until proven otherwise in retrospect. This approach requires adopting a low threshold for intervening in labour and birth, as it has a highly sceptical view of labour physiology. There is focus and monitoring on what can potentially go wrong (Jackson, 2017). Much of the dominance of the technocratic/biomedical model in maternity care has been reinforced by the very powerful presence of the risk discourse.
The characteristics of these models are dichotomous but some midwives and obstetricians would place themselves along a continuum of medical (technological) and social/midwifery (humanistic) approaches to childbirth, and not firmly in one camp or the other (Walsh, 2012).
Why is normal childbirth important?
It is essential to explore what ‘normal childbirth’ is. Within itself, this is fraught with difficulties, as there is no one accepted definition of what normal childbirth is. For instance, normal birth rates have historically been reported as spontaneous vaginal birth, regardless of what other interventions may have occurred (Downe et al, 2001; Downe and Finlayson, 2016). The main definition of normal birth used during this study was the Maternity Care Working Party (2007) definition: ‘normal birth/delivery: without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before or during delivery’.
Evidence shows that childbearing women generally appear to recover more quickly, experience less pain, have an easier breastfeeding experience, bond more quickly with their babies and report higher levels of psychological wellbeing when their labour and birth are normal and straightforward (Green et al, 2003; Sandall et al, 2018; Buckley and Moberg, 2019; Thompson and Feeley, 2019; Lynch, 2020). More frequent adverse outcomes are associated with interventionist, assisted or operative births and are significantly related to negative experiences of childbirth (Green et al, 2003; Baston et al, 2008; Buckley and Moberg, 2019; Thompson and Feeley, 2019; Lynch, 2020). Given the many benefits of normal childbirth, it is somewhat surprising that there is a dearth of research exploring midwifery decision-making during normal labour and birth.
Decision-making in healthcare
Over 50 years ago, Polanyi (1966) wrote about tacit knowledge, a dimension where one knows more than one can explain. Carper (1978) wrote about two contrasting types of knowledge, ‘empirics’ or ‘scientific knowledge’ and ‘aesthetic’ or ‘non-scientific knowledge’. Benner's (1984) work highlighted the difference in propositional and non-propositional knowledge, often termed the ‘knowing that’ (based on science) and ‘knowing how’ (based on experience). These authors' writings and theories have been augmented and added to in psychology, medicine, philosophy and nursing, and are intimately related to theories of decision-making processes (Paley et al, 2007). In naive terms, ways of knowing and decision-making can be divided into rational, rule-based theories, such as the hypothetico-deductive model, and evidence-based practice, or interpretivist dimensions, such as the intuitive-humanistic model. There are also models and theories that are a combination of both, including the dual processing theory, the cognitive continuum of decision-making, ‘mindlines’ and shared decision-making (Mok and Stevens, 2005; Paley et al, 2007; Nieuwenhuijze et al, 2014; Menage, 2016; Jefford, 2019).
Hypothetico-deductive model
The hypothetico-deductive model is systematic-positivistic, rationalistic, analytical, conscious, rule-based and deliberative (Krishnan, 2018). It is the model that appeared to be the most influential in the health decision-making literature, up until the 1980s (Krishnan, 2018). As the name might suggest, this model is considered to be logical, rational, coherent and judicial (Krishnan, 2018). Reed (2004) describes hypothetico-deductive logic as making vertical links between the theoretical and empirical. In the modernist, post-enlightenment period of science, theory and research were connected through specialised systems of inquiry, which were designed to ensure that research was value free and untarnished from the religious and philosophical teachings of the time (Reed, 2004). The most prominent example of hypothetico-deductive thinking in maternity care has been the implementation of evidence-based practice.
Evidence-based practice in contemporary healthcare reflects the fact that decision-making is multi-factorial (Hunter et al, 2008; Greenhalgh et al, 2014; Power, 2015; Daemers et al, 2017). Evidence-based practice can be conceptualised as clinical decision-making that considers the feasibility, appropriateness, meaningfulness and effectiveness of healthcare practices (World Health Organization (WHO), 2017). This may be informed by the best available evidence (hypothetico-deductive and intuitive-humanistic models), the context in which care is delivered, the individual patient or childbearing woman and the professional judgement (intuitive-humanistic and hypothetico-deductive models) and expertise of the health professional (Jordan et al, 2016).
If all of these factors are used, then evidence-based practice can be an effective tool in decision-making. However, if one of these elements dominates, for example, purely clinical experience (essentially constructivist), it could lead to outdated ritualistic practices. If research evidence alone (essentially positivist) was used, this could lead to prescriptive, non-individualised care (Sackett et al, 1996; Thornton, 2006).
Systematic reviews and randomised controlled trials have clearly contributed significantly to evidence-based practice, and are appropriate to answer certain questions regarding health (Mackey and Bassendowski, 2017). However, a limitation of evidence-based practice and clinical guidelines is often cited as the continuing hegemony of positivistic evidence compared to the apparently inferior nature of more qualitative, interpretative forms of knowledge (Goldenberg, 2009; Parkhurst, 2016).
Intuitive-humanistic model
The intuitive-humanistic decision-making model is also known as the phenomenological, affective, non-rational, non-conscious, unconscious or emotional models (Krishnan, 2018). The term ‘intuition’ in this context is defined as ‘understanding without a rationale’ (Benner and Tanner, 1987), ‘immediate knowing of something without the conscious use of reason’ (Schrader and Fischer, 1987) and ‘a perception of possibilities, meanings and relationships by way of insight’ (Gerrity, 1987).
The general principle of the intuitive-humanistic model is that intuitive judgement replaces analytical thinking and is used by experts (as opposed to novices) to make appropriate judgements and decisions, according to Thompson (1999). Supporters of the intuitive-humanistic model would argue that the rational, logical forms of decision-making, which analyse or compartmentalise situations into the sum of its parts, reduce sensitivity, resulting in important information cues being lost, and decision-making is rendered less effective (Thompson, 1999). Alternatively, experienced practitioners use recognition of similar situations to operationalise intuitive knowledge (Mok and Stevens, 2005).
Intuition is not easily studied or articulated. Practitioners often refer to it as having a ‘gut feeling’, but such feelings are difficult or even impossible to measure, and are therefore not highly valued or endorsed by logical positivists, who highlight the primacy of observation as being the only way to assess ‘truth’ (Mok and Stevens, 2005; Siddiqui, 2005). Even if the presence of intuition is acknowledged, there is little scientifically rigorous evidence, at least in the positivistic sense, that it contributes to what might be termed, sound, erudite judgements and decisions (Vlassova et al, 2014). Some may contend that intuition is simply a prosaic accumulation of experience, knowledge acquisition and pattern recognition (Mattson, 2014). Finally, some researchers feel that intuition is not consistently and repeatedly reliable in making important decisions (Dawes, 2002; Greer, 2005) which, in the context of healthcare, could be potentially problematic even catastrophic, in high-risk situations.
Overall, there is emerging robust, empirical evidence that non-rational, intuitive decision-making strategies do have a scientifically verifiable basis and should contribute to evidence-based practice (Koenig et al, 2007; Paley et al, 2007; Mikels et al, 2011; Lufityanto et al, 2016) and be balanced with hypothetico-deductive thinking.
Combined decision-making models
Dual processing theory (Stanovich and West, 2002), the cognitive continuum of decision-making (Hammond, 1988), ‘mindlines’ (internalised tacit guidelines) (Gabbay and Le May, 2004) and shared decision-making (Joseph-Williams et al, 2017) are all decision-making models or theories that combine both rational and intuitive thinking. It could be argued that these better reflect the realities of clinical practice, where the appropriate decision-making approach is used in each unique situation, sometimes alternately and sometimes concurrently.
Methods
All stages of this study were carried out by the author as part of a PhD study. To address the research aim of the study, to explore midwifery decision-making during normal labour and birth, an interpretivist epistemology was chosen. An interpretivist philosopher would argue that ‘reality’ is not a fixed entity, instead it is constructed by individuals and is always context bound. According to Hughes and Sharrock (2016), multiple ‘realities’ are possible. A case-study approach was selected for this study as this fits with the subjective, qualitative nature of interpretivism and with the exploratory aim of the study.
Participants
Hospital-based labour suites and one co-located midwifery-led unit were purposely selected for this study, as this is where the vast majority of childbearing women give birth (NHS Maternity Statistics, 2020) and therefore where most midwifery decision-making will take place. Prior to the study, posters were placed around both labour suites, which included details of the study.
Emails were sent to all eligible midwives (those who worked regularly providing care to women during normal labour and birth), outlining the study's intentions. The researcher attended midwives' meetings and forums to discuss the study and answer any queries.
Data collection
Data collection took place at two case-sites, separate labour suites at two large regional teaching hospitals in the East Midlands. The collected data included focus group interviews, observations during care, diary-keeping by two midwives and documentary reviews.
Three focus group interviews were conducted at each site, including midwives on duty of all band grades who had been qualified for anywhere from 3 months to over 30 years. For logistic reasons, midwives on duty (a convenience sample) were generally selected to take part in the focus group interviews. In total, 10 midwives were recruited at the first site and nine from the second site. The questions related to how they make decisions and what influences their decisions during normal childbirth. Specific questions on decision-making during challenging times in childbirth were asked. For example, when women are in early labour (latent phase) or when labour slows or stops.
A total of 33 midwives were observed at case site 1 during 11 observational visits (total 92 hours) and 34 midwives were observed at case site 2 during 10 observational visits (total 84 hours). The researcher observed and engaged with midwives while they were caring for women in normal labour. Informal conversations took place with the midwives about how they were making decisions, what was impacting their decisions and the degree to which women were involved in decisions. Field and reflexive notes were made throughout the observational visits. In addition, two midwives at case site 1 completed a decision-making diary, documenting their decision-making processes when attending women in normal labour. A documentary review was conducted, searching for relevant information on midwives' decision-making. Midwives were coded MWQ for case site 1 and MWM for case site 2.
Data analysis
A within case thematic analysis was initially conducted (Braun and Clarke, 2006) followed by a cross-case comparative analysis (Stake, 2006; Thomas, 2011). NVivo 10 and 11 were used to manage and code the data, with the analysis being carried out manually by the researcher. The narrative text was read and reread within NVivo numerous times to enable next level codes, categories and main themes to arise from the data.
Ethical considerations
Midwives were initially informed that they could opt out of the study if they wished. In this way ‘implied consent’ was adopted for this part of the research. All midwives who participated in the focus group discussion completed a written consent form.
Ethical principles for research were adhered to, including gaining ethical approval from the local ethics committees (approval no: S13022014 13134 SoHS Midwife) and the local research and development departments of each NHS trust. The heads of midwifery in the trusts involved gave permission for the study to be carried out.
Findlay (2003) asserts that reflexivity is examining how the researcher and intersubjective elements impact and transform research. When carrying out a study, the researcher should be aware of and explore their personal feelings, experiences and values and how these may impact the research. These influences were recognised and integrated into the study (Polit and Beck, 2014).
Results
Following the within and cross case thematic analyses, it became apparent that there was a high degree of parity between the themes and categories (with the exception of two categories) from both case sites.
Five emergent themes were identified:
- ‘The hybrid midwife’
- ‘Woman-focused determinants’
- ‘Midwifery specific influences’
- ‘Environmental and organisational factors’
- ‘Intra and inter-professional influences’.
There were several categories related to each theme (Figure 1). This article focuses on the overarching and central theme, ‘the hybrid midwife’.
Arising from the thematic within case analysis and cross case analysis, the overarching and central theme of ‘the hybrid midwife’ arose from the data. In particular, the concept of midwives straddling two belief systems or having a belief system preference emerged. Tensions and frustrations were apparent for midwives who adopted either a normality-centred or a technocratic approach to care in childbirth, in terms of their philosophy of childbirth and therefore, which decision making strategies were enacted clinically.
Midwives straddling two belief systems
There were several reports from midwives of all grade bands, at both sites, of differences in midwives' approach to childbirth. Some midwives had a more technocratic, medicalised approach to childbirth than others.
‘Some midwives are more medicalised than others, aren't they?’
MWM30, band 6, focus group interview
One band 6 midwife discussed the actions of another midwife who was more medicalised in her practice and decision-making.
‘The lady was all low risk and then she's got everything out for an episiotomy and suturing and all of that's all laid down under the trolley “just in case”, where it's a low-risk lady and there's no need for any of that. And I've put it all away as soon as I've taken over and thought, “Oh, if you need it, you'll get it when you need it.”’
MWM30, band 6, focus group interview
A supporting comment was made by another midwife in the same focus group interview.
‘And especially…if the woman's going to see these things start being produced underneath the trolley, she's going to think “well, what's this? What's that? Why?”’
MWM32, band 6, focus group interview
Changing the environment or ambience was mentioned by a number of midwives. They described how they made the labour suite more conducive to normality by dimming the lights and keeping a calm, quiet atmosphere, where they felt that discussing options, choices and sharing decisions with women was optimised. However, some midwives reported that mediating a serene environment was not always respected by all midwives. Some midwives' believed that others changed and controlled the ambience in the birthing room rather than focusing on and respecting the labouring woman and her decisions regarding the environment.
‘You get that on labour suite…when they come in and they want the lights up and they start having really loud conversations when you've been talking really quietly.’
MWQ32, band 6, focus group interview
During the focus group interviews, several midwives expressed that in their opinion, such behaviour signified an organisational-centred, rather than woman-centred, approach to decision-making. They also reported that they did not always feel that they could challenge more senior midwives belief systems and therefore had to conform to more medicalised ‘management’ of labour and birth.
Midwives' belief system preferences
Some midwives seemed to prefer to operate in one ‘camp’ or the other. There were instances during the observational visits and in focus group interviews, when midwives confirmed their commitment to normality and making decisions based on a holistic midwifery philosophy. During an informal conversation during observations, one midwife, who worked on a midwife-led unit caring for ‘low risk’ women, said she normally encouraged water immersion/water birth for women (MWQ27, band 6).
MWQ27 and other midwives on midwife-led care described doing everything in their power to ensure a woman does not want/need an epidural. This was in part because if they have an epidural, they have to move to the obstetric side of the unit, which may expose them to more medicalised decision-making.
Some midwives preferred more high-r isk, high-dependency care work, which follows a more biomedical, technological model of pregnancy and childbirth and a more rule-based, rationalistic style of decision-making. One midwife (MWM12, band 6) was more into ‘high-risk’ care, commenting further that she cannot fully embrace normality. The reason for her apparent lack of engagement with normality was because of a previous bad experience when caring for a woman who had a physiological third stage birth. The woman had a massive haemorrhage, culminating in a hysterectomy. It was the woman's first baby.
Some band 7 co-ordinating midwives also said certain midwives preferred higher risk care.
‘You hear midwives say…“oh I'm happy with an epidural and synto[cinon]”…junior midwives.’
MWQ5, band 7, focus group interview
‘They'd prefer to care for [women with] an epidural than [a labouring woman] in the water.’
MWQ21, band 7, focus group interview
These band 7 midwives stated that junior midwives were more used to caring for women with syntocinon infusions in progress and epidurals in situ, and that they liked clear guidelines to direct care and decision-making. Midwives at both case sites frequently reported that they felt there were too many inappropriate inductions being conducted. MWQ5 asserted that feeling more comfortable with women whose labours were being induced was to do with the culture of induction being ‘normalised’ and used abundantly in childbirth. She also believed that inductions led to decisions to use a cascade of interventions.
‘It's the way we do inductions…she's started synto[cinon] now…she probably needs an epidural.’
MWQ5, band 7, focus group interview
Some midwife co-ordinators acknowledged different midwives' preferences and skillsets, which will inevitably impact on their decision-making approaches. They recognised that staffing levels and skill mix was an important organisational factor, but that it was not always possible to facilitate midwives' preferences.
A number of senior midwives felt that role and decision-making skills should not be purely caring for ‘low-’ or ‘high-risk’ women but should range through the spectrum of ‘risk’ categories.
‘So therefore, for me, [all practicing midwives have] got to have a real balance of having the knowledge of the absolute normal, right the way through to the incredibly high risk, which, for me, gives them that ability to firstly, confirm normal, recognise deviation from normal and act appropriately.’
MWM26, band 7, focus group interviews
MWM26 believed that all midwives should have the knowledge and skills to care for ‘all risk’ categories, including the associated appropriate decision-making skills. Some midwifery co-ordinators at both case sites tried to match low- or high-risk midwives with low- or high-risk cases (also matching their decision-making skills), but conceded that this was not always achievable.
A number of midwifery co-ordinators at case site 1 spoke about midwives ‘pulling out all the stops’ to promote and maintain normality, using more normality focused, non-interventionist decision-making strategies. Other midwives were reported to make decisions to resort to intervention much sooner:
The co-ordinators knew which midwives will make decisions and try strategies to maintain normality, while others had different approaches.
‘They’ll say “she's been pushing for an hour” or “she needs an epidural”, others you know will have tried everything [water, change of position, aromatherapy] before they come to you. You have to think about which midwife to put with which woman.’
MWQ5, band 7, observations, case site 1
Midwives in the case study environments were operating in dualistic belief systems, in effect being ‘hybrid midwives’. Some functioned as ‘being with’ midwives, embracing a social model of childbirth, and some operated as ‘doing to’ midwives, embracing a biomedical model. In normal, straightforward labour and birth, intuitive-humanistic phenomenological decision-making processes tended to be used. In higher risk situations, hypothetic-deductive, guideline-based, rationalistic decision-making models were reported to be used. It was apparent that some midwives struggled to function in this way, in that some ‘being with’ midwives were under organisational pressure to work as ‘doing to’ midwives, even when caring for women in normal childbirth. In addition, low-risk women's choices and decisions were sometimes not supported because of the business of the labour suite.
Arising from the theme of ‘the hybrid midwife’, the author proposes a more constructive concept of ‘the dynamic midwife’, who balances the challenges of decision-making when caring for both low- and high-risk childbearing women. Consequently, a situated, dynamic midwifery decision-making framework was developed, ‘focus on straightforward labour and birth’. The model consists of two figures, the first based on empirical findings from the present study (Figure 2), and the second based on a continuum of existing decision-making theories, models and influencing factors (Figure 3). This model could be used by midwives to enhance their knowledge regarding different types of clinical decision-making approaches that can be used in normal childbirth.
Discussion
This interpretivist case-study research investigated midwifery decision-making during normal labour and birth. From focus group discussions and observations, five themes emerged to describe decision-making, focusing on a central theme, ‘the hybrid midwife’. Midwives were reported to straddle two belief systems, either a normality-centred or a technocratic-based approach, and some had preferences as to which belief system they used.
Midwives straddling two belief systems
Many midwives favoured either a normality-centred or technocratic-based approach to care in labour and associated decision-making. Midwives were observed and reported to be dealing with high levels of complexity, as well as reporting increasing intervention in normal labour and birth, arguably leading to risk averse decision-making approaches (Walsh et al, 2008; Downe, 2010; Walsh, 2017; Jackson, 2017). Some midwives recognised the impact that making decisions in a ‘what if ’ or ‘just in case’ manner could have on labouring women, potentially increasing their anxiety. The primary role of the midwife has been as a supporter of normal childbirth throughout history (Donnison, 1988). This role could be compromised in such a risk-conscious environment.
Some midwives recognised the difficulties encompassed in social groups working in what Rouse (2002) termed a ‘contested space’. In the present study, the reported contested space was between midwives and obstetricians, the ‘normal’ and the ‘complex’, the low- and high-risk, and the intuitive and hypothetico-deductive decision-making processes. Martinez (2005) discussed ‘borderlands’ as metaphorically helpful for ‘understanding the concepts of health and disease (the physiological versus the pathological) as “referential codes” standing in opposition to one another, and yet straddling a zone where clear delineations among them are problematised’ (Martinez, 2005). Walsh (2010) also highlighted the polarised views of birth and associated decision-making, arguing that women experience birth in the uneasy space between the two.
Vincifori and Molinar Min (2014) conducted a survey of 235 Italian midwives practicing in all areas of midwifery in the Lombardia region. The emerging profile appeared to be the midwife occupying a hybrid space. They discussed that the hybrid midwife experiences the contradiction between what can actually be achieved in hospital-based maternity care and the core values of midwifery (normality, holism, intuition), often drifting unintentionally toward interventionist methods. In their grounded theory study of 15 midwives, Zhang et al (2015) also described a ‘hybrid identity’ of midwives working in an inner city hospital environment in southeast China. Midwives described themselves as negotiating competing identities, one as ‘obstetric nurses’ focusing on risk management (obstetric guidelines, hypothetico-deductive driven decision-making), the other as ‘professional midwives’, advocating normal birth (midwifery intuition-driven decision-making).
A number of midwives in the present study reported struggling to work between competing belief systems. However, a few midwives did appear to work fluidly between all risk cases of women and did not express problems with decision-making in these circumstances, but that does not necessarily mean that such tensions do not exist.
Darra and Murphy (2016) proposed that dichotomous models of maternity care, where midwives work in an entirely medicalised, technocratic or entirely ‘with woman’ midwifery fashion, is unrealistic in the current maternity care system. The working experience of midwives and the lived experience of birth in the UK is somewhere between these two extremes of biomedicine (hypothetico-deductive decision-making) and holism (intuitive decision-making), according to van Teijlingen (2005). However, the way that hybrid midwifery decision-making is enacted in the real world of UK labour suites and the impact of this on health outcomes, has not been the subject of research to date.
Midwives' belief system preferences
Some midwives expressed that they preferred working with low-risk women, and some preferred working with high-risk women. Midwives at both case sites reported that the ‘being with’ and ‘doing to’ midwives (and related decision-making strategies) were known to the co-ordinating midwives, and these co-ordinators tried to match midwives according to the risk status of labouring women. This could be viewed as a positive strategy, matching preferences for low-risk versus high-risk cases. Alternatively, other co-ordinating midwives reported that the role of midwives is caring for the full spectrum of childbearing women (all risk categories) and that midwives should not choose who they do or do not care for. Co-ordinating midwives also reported that facilitating midwives' preferences was often not possible because of the busy status of the labour suite and the lack of an adequate skill mix on duty.
Some researchers have found that midwives working in hospital labour suite settings, serving all categories of women, often make decisions that inadvertently deliver higher-risk intervention strategies to low-risk women (Vincifori and Molinar Min, 2014; Zhang et al, 2015). Resorting more readily to the use of syntocinon to augment labour or to epidurals for pain management assumes more regime, rule-based, hypothetico-deductive models of decision-making.
In the present study, some band 7 midwives proffered that the casual use of induction of labour meant that midwives were comfortable with interventionist, and therefore, more rational, hypothetico-deductive, forms of decision-making. As the induction rate around the time of data collection was 25% (Office for National Statistics, 2017), this is arguably a reasonable assertion.
Cooper (2011) recognised that ‘being with’ (intuitive driven decision-making) midwives often functioned as ‘doing to’ (hypothetico-deductive driven decision-making) midwives, because of the organisational, cultural, and hierarchical maternity systems in place. The author suggests that ‘being with’ midwives in the present study were, at times, not able to enact normality-driven decisions because of constraints.
The situated dynamic midwifery decision-making framework
There was no intention on the author's part to develop a new theory or decision-making tool during their PhD thesis. It is acknowledged that this is usually the role of grounded theory research. However, as a natural inductive process, and with input from relevant existing decision-making and research, a decision-making framework evolved as a result of this empirical study.
The themes and categories arising from the data demonstrated multiple influences on midwifery decision-making. The proposed model is the only model designed for the specific purpose of enhancing knowledge of midwifery decision-making during straightforward childbirth. Figures 2 and 3 demonstrate two different aspects of the complexity of midwives' decision-making. Figure 2 illustrates the influential themes and categories from the present empirical situated, context-based study. This has the woman as central to the decision-making process, with her partner and or birth partner(s) as crucial influences on decision-making. Regardless of midwives' preferences in relation to the type of risk category they work with, the reality of the midwife's role in the UK is that most will be working between both low- and high-risk childbearing women.
Figure 3 shows a decision-making continuum of all traditional and more recent decision-making models and theories. This ranges from the left, where labour and birth is completely straightforward, where more intuitive decision-making will be used, such as watchful waiting, ‘go with the flow’ masterly inactivity (Tew, 1998). To the right, labouring women may develop complications, where the hypothetico-deductive model of decision-making is used, often drawing on evidence-based guidelines.
Figures 2 and 3 constitute the situated dynamic midwifery decision-making framework, with a focus on straightforward labour and birth. This framework could be used for educational purposes. A spectrum of labour and birth scenarioes or vignettes could be used with the framework to prepare midwives and students to use optimal decision-making strategies.
The strengths and limitations of each of the decision making models and theories (Figure 3), related to each vignette, could be debated in a theoretical context. The framework would need to be evaluated first. The situated dynamic midwifery decision-making framework is the only framework dedicated to normal labour and birth and is a unique contribution to the field of midwifery decision-making.
Conclusions
Decision-making in normal labour and birth is a complex phenomenon, influenced by factors exemplified by the themes found in this study. The hybrid midwife has to frequently balance decision-making strategies that are appropriate for childbearing women in all risk categories. They appear to not always be well-prepared for the challenges of decision-making for women in normal labour and birth in the context of obstetric-led care.
Further research and education is required to improve knowledge of midwives' decision-making. The situated dynamic midwifery decision-making framework, ‘focus on straightforward labour and birth’ would benefit from evaluation in educational settings.
Key points
- Decision making during normal labour and birth is a complex phenomenon, influenced by a multitude of factors.
- Midwives may beneft from educational input on decision making approaches. This input should include which strategies could better support women during normal labour and birth.
CPD reflective questions
- Which decision making strategies do you use in clinical practice when caring for women in normal labour and birth?
- How can you use your decision-making approaches to enhance normality/humanisation of childbirth?