Midwifery decision making during the first stage of labour within the Malawian context

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.