faculty of midwifery education & studies maastricht maternal distress - what do midwives do and...

Faculty of Midwifery Education & StudiesMaastricht

MATERNAL DISTRESS - What do midwives do and what motives do they have?

A two-phased exploratory study

Yvonne Fontein RM MSc PgDHE

[email protected]


MATERNAL DISTRESS - What do midwives do and what motives do they have? A two-phased exploratory study

Phase I - Qualitative interviews (Sept 2011- Feb 2012)

Phase II – Quantitative sample survey (March –Sept 2012)

*Research ethics committee Atrium-Orbis


PHASE I. Qualitative interviews

AIM To gain insight in and familiarity with midwives' behaviour and cognitiveprocesses and perceived influences on the utilization of the midwife's care forpregnant women with maternal distress



Critical organisational-ethno methodological approach

Purposive sampling•Six midwives

Individual semi-structured interviews•Scott-Morgan method•Use of visual-narratives

Analysis: Nvivo8•Theory of Planned Behaviour


Theory of Planned Behaviour (TPB)

Attitude

Subjective norm Intention BEHAVIOUR

Self-efficacy

Ajzen (1991) Barriers



RESULTS: BEHAVIOUR• Diverse practice (Yelland et al 2007)

• Care unstructured, embedded in daily practice• Midwives identify competencies, skills and routines/ habits

and learned patterns; less clear about screening• Performance influenced by perceived level of experience,

interest, views of professional remit, sense of responsibility and competence, ability and willingness to address maternal distress

“…Because of my daughter’s problems [ ], I am much more aware of how women feel and need help and support…”

“… Screening questionnaire? [ ] EPDS? Heard about it. Wouldn’t know how to use it though…”



RESULTS: ATTITUDE• Maternal distress is a serious problem • Is part of midwife’s scope of practice• Not always sure what to do and how to do it and how it fits

in the continuously expanding tasks of the midwife or their task-orientated attitude

• Autonomy of the woman• Intense

“….I really think I should ask women about it, but please tell me how…”

“…Sometimes I just don’t want to know or hear what [ ] goes on in a woman’s life…”

“…You just know it when something is wrong but I respect it when a woman doesn’t want to tell me…”



RESULTS: SUBJECTIVE NORM• Women’s perception of pregnancy, maternal

transition and maternal distress

“…Sometimes I sense women do not want to talk about it, because they think they should be happy [ ], that pregnancy should be a happy thing and that there should be no reason to complain…”

“…I think they expect me to ask about it [maternal distress]…”



RESULTS: SELF-EFFICACY• Confident of personal and professional

capabilities and competence• Less confident about screening and referral

skills• Less confident about knowledge

“…I know I can support women with maternal distress but sometimes I keep my fingers crossed, hoping that I am doing the right thing because I am not always sure, but I really do hope so…”



RESULTS: INTENTIONIntentions are clear on macro level but less

explicit on meso and micro level

“…I really would like to make a difference in the health and happiness of the new generation…”

“…Making a health & social care map seems like a good idea to do at some point [ ] soon…”

“…Well, I should look for some information or conference or something about maternal distress, shouldn’t I…?”



RESULTS: BARRIERS• Barriers: Lack of education (Buist et al, Yelland et al 2007, Jones et al 2011, McCauley et

al 2011), guidelines for screening, clinical pathways and knowledge/ insight other health professionals and the organisation of own practice affects care

• Supportive: Relationship with the woman; environment of woman; education; research, health & social care map; inter-disciplinary collaboration and reflection are helpful

“…I don’t ask women about maternal distress because I have no idea who to refer to, so what’s the point…?”


PHASE I. Qualitative interviews CONCLUSION• A first insight in midwives’ perspectives and subsequent

behaviour patterns was captured, allowing to make sense of the midwife’s everyday practice in regard to maternal distress

IMPLICATIONS• Provides sufficient information to serve as a foundation

for questionnaire development phase II


PHASE II. Sample survey

Aim To explore midwives' behaviour andthe determinants of this behaviour in regard to antenatal care for women withmaternal distress


PHASE II. Sample survey Convenience sampling (141 clinical placement practices, newsletter KNOV)•N = 112

Digital distributed questionnaire (Questback) structured on TPB•Behaviour constructs according NICE (2007), SOSU (2007)

•Pre-test•7 point Likert response scale 1 – 7

SPSS (19.0)•Cronbach’s Alpha scores•Principal Component Analysis •Multiple regression analysis (TPB)


Expanded model Theory of Planned Behaviour (TPB)Personal/ demographic Details age, work Attitude sub-

experience, education, work- behaviour, maternalrelated stress distress, prevention in general

Subjective norm

Work-related details Intention BEHAVIOURpractice size, practice- screening,

assistant, routine provision support, referral,

health information Self-efficacy collaboration

Knowledge source

pre-registration, post- registration, LLL, self-study,

web, practice, personal Barriers


Characteristics participants N = 112Variable Mean (SD) N / %Age 36.12 (10.03)

Experience (in years) 11.76 (9.44)

Education: diploma 30 / 26.8% BSc 75 / 67.0%

MSc/ PhD 7 / 6.3%

Work-related stress (scale 1 – 7 strongly disagree – strongly agree) 4.08 (1.08)

Practice size: solo 8 / 7.1%

duo 15 / 13.4%

3-4 midwives 53 / 47.3%

5 or more midwives 34 / 30.4%

Practice assistant 72 / 64.3%

Routine provision health information 84 / 75 %

Main knowledge source: pre-registration 20 / 17.9%

post-registration 8 / 7.1%

congresses/ seminars/ work-shops 24 / 21.4%

self-study 6 / 5.4%

web 1 / 0.9%

practice experience 46 / 41.1%

personal experience 7 / 6.3%


Screening behaviour Maternal Distress (MD) 4.48 (SD 0.75)(1 strongly disagree – 7 strongly agree)

Routinely asking for MD at booking and subsequent antenatal visits

Routine use of standardized question for MD at booking

Use of a validated screening questionnaire at booking when MD is reported or as routine practice

Trying to establish the source when MD is reported


Multiple regression screening behaviour

Positive contribution Negative contribution

R2 .511 Sig. F Change <. 001


Supportive behaviour Maternal Distress Mean 5.61 (SD 0.40)(1 strongly disagree – 7 strongly agree)

Actions at booking: reporting in file, re-visiting the subject, awaiting further development

Actions at subsequent antenatal visits: further exploration of problems, advice on how to cope, extra visit, home-visit, asking what the woman needs from midwife, reporting in file, re-visiting the subject

Information provision of maternal transition, psychological changes during the childbirth process, consequences of maternal distress

Asking about feelings and evaluating the experience of the (forthcoming) birth

Use of guideline ‘Antenatal support’


Multiple regression supportive behaviour


R2 .620 Sig. F Change < .001


Referral behaviour to other (specified) health professionals Mean 5.61 (SD 0.51) (1 strongly disagree – 7 strongly agree)

Advice to seek a health professional for maternal distress at booking or subsequent antenatal visit

Active referral to a health professional for maternal distress

Use of a health & social care map

Referral to specified health professional (General Practitioner, obstetrician, paediatrician, psychologist, social worker, alternative therapist, antenatal education, organization for mental health care (GGZ), psychological coach, outpatient services for pregnancy and psychiatry (POP), social services)


Multiple regression referral behaviour to other (specified) health professionals

Referral behaviour

Self-efficacy β=.356 t=3.501 p= .001

Positive contribution Negative contribution R2 .364 Sig. F Change .002


Collaborative behaviour with other health professionals Mean 5.09 (SD 1.01) (1 strongly disagree – 7 strongly agree)

Internal practice discussions/ meetings of women with maternal distress and clients

Consultation of General Practitioner

Transfer of information to other health professionals (health visitor, maternity care)


Multiple regression collaborative behaviour


R2 .319 Sig. F Change .013


PHASE II. Sample surveyCONCLUSION• Various determinants are associated with the different

constructs of behaviour • Screening behaviour has many determinants in

comparison to the other behaviour constructs• Multiple psychosocial issues play a role in regard to

screening behaviour while only attitude is associated with support and self-efficacy with referral and for collaboration psychosocial issues hardly play a role

IMPLICATIONS• The findings of this study will be used to contribute to the

development of an intervention


REFERENCES

Ajzen, I. (1991). The theory of planned behaviour. Organizational Behaviour and Human Decision Processes. Vol.50:179–211

Buist, A., Bilszta, J., Milgrom, J., Barnett, B., Hayes, B., Austin, M.-P. (2006) Health professional’s knowledge and awareness of perinatal depression: Results of a national survey. Women and Birth. Vol. 19: 11-16

Jones, C. J., Creedy, D. K., Gamble, J. A. (2011) Australian midwives’ knowledge of antenatal and postpartum depression: A national survey. Journal of Midwifery & Women’s Health. Vol. 56 (4): 353-361

McCauley, K., Elsom, S., Muir-Cochrane, E. (2011) Midwives and assessment of perinatal health. Journal of Psychiatric and Mental Health Nursing. Vol. 18: 786-795

NICE (2007)Antenatal and postnatal mental health. NICE clinical guideline 45. National Institute for Clinical Excellence

SOSU (2007) Perinatal depressive and anxiety disorders. Statewide Obstetric support Unit. Western Australia: Women and Newborn Health Service.

Yelland, J., McLachlan, H., Forster, D., Rayner, J., Lumley, J. (2007) How is maternal psychosocial health assessed and promoted in the early postnatal period? Midwifery. Vol. 23: 287-297

faculty of midwifery education & studies maastricht maternal distress - what do midwives do and...

Documents

maternal distress slide

qualitative interviews

midwives behaviour

attitude maternal distress

exploratory study phase

maternal transition

daily practice midwives

pregnant women