Midwifery decision making during the first stage of labour within the Malawian context
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Date
01/07/2016Author
Chodzaza, Elizabeth Chifuniro
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Abstract
Background: Concerns have been well documented about women either dying or developing
severe morbidities from prolonged and obstructed labour. These concerns have noted that
maternity care during labour has not been of a sufficient standard to improve the outcome for
women giving birth in Malawi. This ‘failure to save’ women remains, despite assertions that
obstructed and prolonged labour can be prevented through appropriate decision making
during the progress and management of labour. Midwives in Malawi form the majority of
maternity healthcare workers and an important aspect of their decision-making role is to
assess the progress of labour when caring for women in labour. To date, there has been
limited exploration of either midwifery decision making during labour or the contextual
factors that influence midwives’ decision making. The aim of this study was to explore how
Malawian midwives make decisions during the first stage of labour in a hospital setting and
to identify the contextual factors that influence their decision making.
Design and Method: Using a qualitative ethnographic research approach, 27 participant
observations, 26 follow-up interviews and document reviews comprised the data collection.
Nine Malawian nurse-midwives who worked at a tertiary (n=5) and a secondary referral
hospital (n=4), with a mixture of qualifications and experiences, participated. Each nurse
midwife was observed three times with subsequent follow-up interviews. Interviews were
conducted in a vernacular language, audio-taped, transcribed, translated into English and
back translated into vernacular language. Qualitative data analysis software, NVivo 10, was
used to assist with data management for the analysis. All data was analysed using the
principle of theme and category formation.
Findings: Three major themes were identified
- contextual factors influencing midwifery decision making
- the role of cue acquisition
- the role of the partograph during care of women in the first stage of labour.
Integration of the themes has led to the development of a proposed conceptual model of
‘supporting normality’ during the first stage of labour, which suggests that the midwives
strived to make decisions during the care of women in labour with the aim of supporting the
normal physiological processes of labour.
The first theme illustrates that for Malawian midwives, decision making is a complex and
contextually dependent undertaking. In everyday practice, decision making was influenced by
multiple and competing factors but the midwives developed strategies to manage and control
the context of their practice and facilitate decision making.
The role of cue acquisition comprised a six-stage subprocess illustrating the ways in which
midwives utilise assessment data to reason and make decisions during the care of women in
labour. These processes involved the midwives building a case for each woman’s labour
progression by piecing together segments of information they obtained. This process was
striking when there was uncertainty in a woman’s progress of labour as they used deductive
thinking by cross-checking data obtained across the labour progression span. There was a
constant forward and backward moving of thought processes supported by actions that
uncovered real case-building evidence for informing decisions about whether to intervene or
not.
The model further indicates the role of the partograph, which alerted midwives to the
presence of progress or non-progress of labour. Although the partograph acted as an adjunct
to the midwives’ decision making that could indicate opportunities for early intervention in
labour if labour appeared not to be progressing, the midwives were sometimes cautious about
its interpretation.
This thesis has expanded on current theoretical knowledge of decision making by elaborating
on the processes midwives employ to make decisions as they care for women in labour. It
also illuminates the impact of contextual factors on decision making, and elucidates various
strategies midwives use to advance their professional role. The emerging conceptual model
provides implications for future midwifery practice, education and policy both in Malawi and
worldwide.
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