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Background: A public inquiry into failings in maternity services and care in England (Kirkup, 2015) identified that the dual roles of midwifery statutory supervision, namely support and regulation, should be separated. As a result, support was to be delivered by introducing new clinical supervision models provided by employers of midwives, and regulation was the sole responsibility of the Nursing and Midwifery Council. The new model of clinical supervision in Scotland was launched in 2018 after statutory supervision of midwives ended in 2016, and this study evaluated its implementation and midwives' participation in the new model. To begin the study, a systematic review of the literature was completed, which identified that no empirical research existed about the new model of clinical supervision, how it was implemented or midwives' experiences of participating in it. Aims: To understand and analyse midwives' participation in the new model of clinical supervision in Scotland and how this new model was implemented. Methods: A qualitative case study design was used to evaluate Scotland's new model of clinical supervision. Purposive sampling and snowballing strategies were utilised to select midwife participants who had participated in clinical supervision. In-depth semi-structured interviews were conducted at 1) a meso-level with ten Heads of Midwifery in ten NHS Health Boards and 2) at a micro-level with eighteen midwives in two case sites. Additionally, four non-participant observations in the two case sites were completed. A theoretical framework was used to design and present the study using four of Proctor et al.'s (2011) implementation outcomes, acceptability, adoption, feasibility, and fidelity. In addition, framework analysis (Gale et al., 2013) was used to analyse the generated data. Findings: The findings identified three main factors 1) time, 2) trust, and 3) perceptions of clinical supervision as a tick-box exercise were the main barriers to implementing clinical supervision and midwives' experiences of participating in it. First, the time available to prepare for and participate in clinical supervision was limited. As the new model was delivered predominantly in groups, participants were affected by a lack of trust in groups which affected their participation. Finally, clinical supervision was perceived as an item to 'tick off' to evidence attendance. Conclusions: This study revealed that the acceptability of the new clinical supervision model was affected by how it was delivered and the content of the new model, especially reflection and resilience-building. The adoption of the new model was impacted by how often midwives participated in clinical supervision, which was affected by advertising and promotion, and the simultaneous implementation of a major new midwifery policy, Best Start (Scottish Government, 2017). Significantly, the previous model of statutory supervision influenced midwives' engagement with and the uptake of the new clinical supervision model. Clinical supervision was considered a feasible intervention, although its feasibility was affected by midwives' feelings and emotions related to participation and the lack of resources available to deliver the intervention. Finally, midwives showed varied understanding of the new clinical supervision model, which altered the ability to adhere to and deliver clinical supervision as intended.

Musculoskeletal symptoms have been problematic for healthcare staff, resulting in sickness absenteeism, functional limitations, staff shortages and financial costs to organisations. Maternity professionals who care for women in labour, particularly midwives and obstetricians, are also at high risk of developing musculoskeletal disorders due to a range of associated risk factors including heavy working conditions and awkward caring positions. There has been, however, limited research into this condition in midwives. The aim of this thesis is to investigate musculoskeletal disorders with prevalence, distribution, severity and impact, and to explore contributing factors from a biopsychosocial perspective. A first stage survey study (n=635) explored the extent of musculoskeletal disorders and association with risk factors. The Nordic Musculoskeletal Questionnaire identified a very high prevalence of symptoms, mostly in the lower back (71%), neck (45%) and shoulders (45%) within a 12-month period. These symptoms resulted in activity limitation (50%), sickness absences (30%) and change of job/duties (45%). An investigation into the associations between potential contributing factors and musculoskeletal symptoms showed that younger age, less experience in the profession, a higher body mass index, longer working hours, lower job satisfaction and higher job stress can each play a role in developing such symptoms. In-depth interviews with 15 midwives and a further validation focus group (n=7) explored risk factors and prevention strategies in considerable detail. The majority of such symptoms were considered to be work related, including working tasks, equipment, environment, heavy workloads, staff and mother characteristics. The primary concern expressed by midwives was the lack of application of protective strategies in real practice due to the heavy workload and mother-centred practice approach. They also argued that they did not benefit from standardised manual handling training due to a lack of content dealing with midwifery caring activities. Finally, the risk of musculoskeletal symptoms associated with common working positions was evaluated by using the Rapid Entire Body Assessment postural analysis tool with a sample of midwives (n=22). This analysis suggested that working postures resulted in a significant increase in the risk of developing musculoskeletal disorders, with all postures having a very high to medium risk level, indicating that immediate action is required to address this issue. The trunk, neck and upper arm were found to be the most commonly affected body parts. The findings will inform the development of risk management strategies to reduce musculoskeletal symptoms in the absence of such data in the United Kingdom. Management of such symptoms may have a positive impact on staff shortages, early retirements, individuals' life trajectories, mother and baby safety as well as staff wellbeing. Organisations and professional bodies play a key role in this regard.

Background Midwives are expected to perform multiple health promotion practice behaviours (HePPBes) such as informing pregnant women about the benefits of physical activity during pregnancy and asking women about their alcohol consumption. However, no formal support appears to be available to midwives in carrying out these tasks. This thesis describes the systematic development of an evidence-based, theory-informed intervention to support midwives in addressing health behaviours with pregnant women. Methods This thesis consisted of four phases. Phase 1: review of the evidence including key documentation and a narrative review to identify interventions to support midwives’ HePPBes. Phase 2: semi-structured interviews with midwives (N= 11) based on the theoretical domains framework and an online questionnaire assessing midwives’ views on HePPBes (N= 505). Phase 3: systematic development of the HePPBe toolkit, integrating: i) target population, ii) target behaviours, ii) theory, iv) behaviour change techniques and v) format of delivery. User, patient and public involvement was carried out throughout phase 3. Phase 4: online questionnaire to assess midwives’ preliminary views (N= 108) on the acceptability of the newly developed HePPBe toolkit. Results and conclusions A review of existing evidence identified multiple policies and guidelines implicating midwives in performing HePPBes. However, no peer-reviewed literature reported interventions to support midwives in carrying out their HePPBes. New evidence found midwives perceived barriers to carrying out HePPBes, such as a requirement to perform an increasing amount of HePPBes on top of existing clinical workload. Facilitators, including strategies used by midwives to perform HePPBes, were also identified. Performance of HePPBes was predicted by psychological factors, including confidence, intrinsic drive, and feelings of being supported. These findings informed the development of a handheld HePPBe toolkit with evidence of preliminary acceptability. This thesis provides a practical example of how to systematically develop a multiple behaviour change intervention for, and in consultation with, healthcare professionals.

This thesis reports on a qualitative exploration of the lived experience of seven pregnant women, medically classified as severely obese, and subsequently labelled as a high-risk pregnancy. Aims: • To explore perception of risk during childbirth in women with an increased BMI > 35kg/m2. • To explore how their childbirth experience and birth outcome impacts on risk perception over the pregnancy continuum. Background: The concept of "maternal obesity" and "risk" is particularly pertinent to midwifery care today. It has been well documented that maternal obesity represents an increased risk of mortality and morbidity to both mother and baby, and as a result is classified as a "high-risk" pregnancy. This thesis draws on the influence of the French philosopher Foucault's work on governmentality, which encourages health care systems to introduce guidelines and interventions to regulate the obese pregnant body. Adjacent to this is an expectation that the "good mother" will conform to such guidelines, which recommend monitoring, regulation and disciplining of the body. In relation to this, the thesis focuses on the joint guideline: CMACE/RCOG (2010) Management of Women with Obesity in Pregnancy, and the high-risk pregnancy journey of seven pregnant obese women. Methods: This is the only existing longitudinal qualitative study, using a hermeneutic phenomenological approach (IPA) has provided an in-depth exploration of the obese pregnant women's perception of their own risks. Seven pregnant women were recruited using purposive sampling, with data collected using semi-structured interviews conducted at 18 - 22 weeks, 34 - 36 week's gestation and 10-15 days postnatal. Datum was analysed using an Interpretative Phenomenological approach (IPA). Findings: Analysis was performed, with four superordinate themes emerging from the results of this study. These included 1) Choice, continuity and control, where some of the participants expressed the need to feel in control of their birth experience, but once they started to experience complications they were more ready to relinquish responsibility to health care professionals. 2) Me and my body, where the participants own body image was not congruent with that of the obese body. Consequently, they rejected the obesity label. 3) No risky talk, which uncovered that despite being categorized as a "high-risk" pregnancy, the women were very aware that health professionals avoided any risk communication. 4) Risk or no risk, with this final theme concluding that in light of their own experience and what participants had observed in friends and family, that they were no more at risk of complications than women with a normal BMI. This thesis proposes a conceptual framework named "my risky self", which was developed from the four themes identified in this study. Current literature, which included cognitive heuristics, the psychometric model of risk perception and Cooley's (1902) looking glass theory, were applied as a new way of understanding risk perception in obese pregnant women. Conclusion: The findings highlight the need for specific training for health professionals, and midwives in particular, which focuses upon developing knowledge around obesity related risks, support services available and weight management during pregnancy. Midwives also require more training in communication skills to support them to approach this sensitive subject more effectively and affectively.

Aim Over the last two decades, ultrasound imaging and practice has undergone a significant transformation shaped by political, cultural, sociological, technological and educational influences. Furthermore, the continual rise in the demand for ultrasound examinations is outstripping supply. This has had several reverberations and ramifications for the dynamics, constitution and wellbeing of the sonography workforce. Moreover, the adoption of ultrasound technology by various professionals has resulted in professional fission and fusion with both vertical and horizontal substitution within this heterogeneous workforce. It is against this backdrop that newly qualified sonographers enter the workforce. One under-researched area is an understanding of the experiences of these newest members of this multi-disciplinary workforce. Methodology A case study methodology was utilised which explored the experiences of newly qualified sonographers in their first year of ultrasound practice. The newly qualified sonographers were from a multi-disciplinary background. A conceptual framework was initially developed to guide the discovery phase of this research. Data was collected from eleven participants using face to face interviews and work diaries. The data sets were analysed using thematic analysis. The findings of the research were then embedded into the conceptual framework. Findings Three main overarching themes from eight subthemes were identified, namely; transition, role development and maintaining competency and credibility. The knowledge and understanding generated has broader benefits not only for the individual professional but also for ultrasound educational curricula, individual organisations and professional bodies. Experiences of newly qualified sonographers can be improved by developing specific preceptorship programmes in the initial period of transition whilst drawing upon theories such as cognitive apprenticeship and situated learning to facilitate role development after qualification. For organisations with a multidisciplinary ultrasound workforce, the fostering of communities of practice should be encouraged as a social learning environment. These strategies will promote the future role and development of the sonographer and create a greater sense of professional pride, belonging and security whilst supporting both uni-professional and cross-boundary ultrasound working.

Background: The professional development of midwifery in China has been challenged by its marginalised professional status and the medical dominance within midwifery practice in the contemporary maternity care system. There has been growing confusion about, ‘Who the midwife is and what does the midwife do?’ within and outside the profession. The sense of identity crisis for the profession has become particularly salient when Chinese midwifery becomes a sub-branch of the nursing profession during the contemporary period. If, however, we consider the International Confederation of Midwives (ICM) Mission Statement (2008: 32) that midwives are the ‘most appropriate professionals for childbearing women in keeping childbirth normal’, then the focus on a greater understanding of midwives is needed. It is the aim of this research to facilitate this understanding by exploring how hospital-based Chinese midwives construct their professional identity in the contemporary maternity care system and the factors that significantly influence the process. Design and Method: A Constructivist Grounded Theory (CGT) study was conducted to achieve the research aim. A sample of 15 midwives and 5 women participants was recruited between October 2010 and May 2011 from a capital city in one province of China. The accounts from the participants in the form of in-depth individual interviews were digitally recorded and three work journals from midwife participants were also included to facilitate the exploration of the study subject. NVivo 8 was used to assist with data management for the analysis. Findings: Six principle categories were identified: ‘institutional position’; ‘organisational management’; ‘professional discourse’; ‘compromising strategies’; ‘engaging strategies’; and ‘hybrid identity’. The integration of the principle categories has developed the theoretical model ‘navigating the self in maternity care’, which suggests that professional identity construction in midwives is a dynamic process, involving a constant structural and attitudinal interplay between the external (‘obstetric nurse’) and internal (‘professional midwife’) definitions of the midwife. The model indicates that the midwives’ professional identity construction was contextualised in their ‘institutional position’ in the contemporary maternity care system. In everyday practice, midwives experienced identity dissonance in relation to two competing identities: the ‘obstetric nurse’, bound up to the ‘organisational management’ in hospital settings; and the ‘professional midwife’, associated with the ‘professional discourse’ in the midwifery profession. Two types of strategies were identified to reduce the identity dissonance – ‘compromising strategies’ and ‘engaging strategies’ – which resulted in a ‘hybrid identity’, as the construction of professional identity in individual midwives is navigating along an identity continuum with ‘obstetric nurse’ and ‘professional midwife’ at opposing ends. This thesis has expanded on the current theoretical knowledge of identity work by elaborating on the discursive practices professionals employ to legitimate their professional identity and the various strategies individuals use to negotiate their identities at work. It has also extended attention to the influence of institutional forces on professional identity construction. With specific regard to Chinese midwifery, this emerging theoretical model provides a number of possible implications for midwifery practice, education and policy which would facilitate the exploration of effective operational processes for midwives in China to develop professionally.

Midwives are often the lead providers of maternity care for women. To provide the variety of care required by women, they need to be confident in their role and practice. To date, only limited evidence exists in relation to confidence as experienced by midwives. This thesis aims to explore the phenomena of confidence through the lived experience of midwives. In particular, this will encompass confidence in the context of the intrapartum care setting. The theoretical basis for the study was hermeneutic phenomenology, guided by the work of Heidegger and Gadamer. Midwives were recruited from three clinical settings to obtain a diversity of views and experiences. Rich data from diaries and in-depth interviews, from twelve participants, provided insight into the phenomena of confidence and the factors midwives encountered that affected their confidence. The phenomena of confidence consisted of a dynamic balance, between the cognitive and affective elements of knowledge, experience and emotion. This balance was fragile and easily lost, leading to a loss of confidence. Confidence was viewed as vital to midwifery practice by the participants of the study; however, maintaining their confidence was often likened to a battle. A number of cultural and contextual factors were identified as affecting confidence within the working environment, including trust, collegial relationships and organisational influences. Midwives also described various coping strategies they utilised to maintain their confidence in the workplace environment. This study provides unique insight into the phenomena of confidence for midwives working in intrapartum care, resulting in a number of recommendations. These highlight the importance of leadership, education and support for midwives in the clinical environment in enabling them to develop and maintain confidence in practice.

This thesis presents a case-study of interprofessional working in one English NHS maternity unit. Problematic interprofessional working in UK maternity care can contribute to poor outcomes for women using the services, as well as to difficulties for midwives. Relevant research to date has focused mainly on midwife-doctor relationships. Associated social factors, namely, issues of gender, power, professionalism and the medicalisation of birth, have been identified over the last two decades; however, there have been only sporadic improvements in this area. There has been no in-depth study of how micro-level discursive mechanisms affect midwives" interprofessional relationships. The aim of this study was to explore how midwives" discursive practices relate to the social factors listed above. Critical Discourse Analysis (CDA) was applied to 17 midwife-authored research papers and four documents governing midwifery practice. Semi-structured interviews were conducted with 19 midwives, and 100 hours" observational data were collected over a period of one year. A sampling strategy of maximum variation resulted in the recruitment of interview participants of differing seniority, practice locale (hospital/community) and involvement in role extension. Additional interviews were conducted with four obstetricians and seven service-users. Interview and observational data were analysed following both thematic and CDA principles, in order to aid identification and examination of pertinent discursive practices. Out of 17 relevant social practices identified, 13 involved midwives" discursive practices which reinforced traditional notions of professionalism, gender and the medicalisation of birth. However, most midwives in the unit expressed satisfaction with their interprofessional relationships; this appeared to hinge on the fact that their interaction with the obstetricians in the unit were grounded in the shared exercise of power. Midwives" relationships with some other occupational groups were more problematic, particularly where they had similar status in the occupational hierarchy. A key finding was that good interprofessional relationships between midwives and other staff did not necessarily enhance women"s experiences of maternity care. The thesis contributes to the knowledge base about interprofessional working among midwives by developing a theoretical approach concerning the relationship between communication and the operation of power in their working environments. It has also produced findings about midwives" relationships with both medical and non-medical colleagues. Implications are discussed concerning midwifery, women using the maternity services, and our society"s approach to birth.

This dissertation will analyze the underlying reasons childbirth became professionalized, which was due to the growing demands by women for safer birthing conditions. The demand evolved out of the complex relationship among social status, race and ethnicity, and regional locations, all made possible by the modernization and professionalization of tocology that became available during the latter part of the nineteenth and beginning of the twentieth-century. The history of childbirth is a critical topic because, as previously mentioned, the maternal mortality rate in the United States in the twenty-first-century is still incredibly high for a developed nation. Women deserve safer birthing conditions. Those who assist in ushering new life into the world are responsible for protecting both mother and infant. This work will primarily focus on the transformational period of the professionalization and modernization of childbirth; however, it is critical in some instances to extend the time frame to gain a better understanding of the matter at hand. Text Summary Chapter 1 briefly introduces the art of childbirth, discussing the evolving relationship between socioeconomic groups. Additionally, the reader is introduced to the examination region, rural Alabama: specifically, Hale, Greene, Dallas, Sumter, and Marengo Counties. The region was selected for its unique socioeconomic climate. In the nineteenth-century, the field of academic obstetrics was in its infancy. Midwives and physicians had a turbulent relationship as both thought the other was intrusive and careless. However, it is necessary for a woman to be accompanied by a birth attendant during delivery to help preserve the life of both mother and child—a point that both physician and midwife agree upon. The question becomes who is better at providing healthcare to both mother and infant while preserving the cultural climate that these women so desperately want. Who knows what is best for the parturient and why becomes a focal point for this dissertation with the ultimate goal of analyzing the overall thesis. This dissertation will argue that the reason for the professionalization of childbirth was due to the growing demand by women for safer birthing conditions that developed around the evolving relationship among social status, race and ethnicity, and regional location distinctions; reform was made possible by the modernization of medicine and the professionalization of tocology available during the nineteenth- and twentieth-centuries in America. Chapter 2 will examine the socioeconomic climate of rural Alabama, specifically in Hale, Greene, Dallas, Sumter, and Marengo Counties. These counties are five of the wealthier counties in Alabama during a period of extreme poverty. From 1870-1910, Alabama had a shifting diversity of ethnicity as it experienced a period of White Flight. This period was when more Whites left Alabama than entered or resided in it, providing open opportunities to the newly freed Black population. This chapter analyzes the trends in population shift as well as the financial stance of the region. Through census data, historians can better understand the class struggles in Alabama; however, the data is imperfect, presenting obstacles at every turn. Additionally, this chapter will analyze the vital statistics presented for Alabama from 1870 to 1910 to illustrate the maternal and infant mortality rates in the state, nation, and world. Chapter 3 analyzes the question “Why Are You the Way You Are?” to understand the growing tension among society, midwives, and physicians. To attempt to answer that question, the geo-occupational configuration of the population will illustrate the high rural population and the agricultural occupations of the state’s inhabitants. Alabama’s population was mostly rural farm workers of both genders. This chapter will further analyze the causes for women working in agriculture and why that was important to childbirth. Moreover, racial ideology will be examined in relation to quality birth attendants, education, and the societal pressure to ignore the Black population through the lens of the Disappearance Hypothesis. Lastly, as statisticians examine the vital statistics of the region reformers recognize the need for intervention because of the presented statistical analysis drawing parallels between race and death rates. The question becomes how? Chapter 4 discusses The Problematic Midwife. In a rural, poor, primarily Black population, women still needed quality birth attendants. Physicians were too expensive for the majority of parturients, so they leaned on the support of Granny midwives. The women did more than catch babies as they entered the world; thus, socially, they were accepted and respected, at least until physicians began to attack their lack of education. But who was to blame- the overworked, undereducated midwife who was doing the best that she could or the overpriced classically trained physician? The midwives were victims of societal making, damned if she did and damned if she didn't. Chapter 5, Along Came a Doctor, examines the medical revolution the United States underwent during the latter part of the nineteenth-century through the twentieth-century. Medical schools were evolving, and with them, a new specialized physician was looking for a better society and an increase in social and financial status. The quest for the “almighty dollar,” as Washington Irving called it, may have altered many physicians' regional path and moral compass. As medical advancements stimulated change for patients within hospitals, Blacks were excluded from such services due to Jim Crow Laws. The modernization of tocology was developed to provide physicians with the skills necessary to assist in delivery; however, ethical dilemmas arose from learning techniques. Men like Dr. J. Marion Sims and Josiah Nott utilized Black women in developing medical procedures, often with little pain management, which they justified through the assertion that Blacks experience less pain than Whites. Moreover, academia struggled with the ethical dilemma of practicing their skill on pregnant women. It takes creativity to overcome this challenge to educate blossoming physicians. In conclusion, the transitional period between home and medically sanctioned childbirth deserves additional research. While scholars claim that modernizing obstetrics made childbirth safer, I argue that the more accurate assertion is that it changed childbirth. Midwives who had limited resources provided for a community unselfishly in an attempt to fulfill a need. That selfless commitment was demonized and degraded because of their race or social status. Had the Granny midwife been a White wealthy male, he would have been hailed a hero for his efforts; however, the political, social, and economic makeup of rural Alabama generated the perfect conditions to allow hatred to grow.

Obstetric violence (OV) at the hands of health care providers (HCPs) violates fundamental human rights and can significantly impact the physical and psychosocial health of women and their families. OV includes unconsented interventions, coercion, disrespect, overmedicalisation and abuse. International research indicates that around one third of women experience birth trauma with OV contributing to this distress. Whilst research has been undertaken regarding midwives' perspectives of OV in low- and low-middle income countries, there is scant literature regarding the perceptions of midwives from high-income countries, including Australia. This study aimed to explore midwives' perspectives of OV within the Australian context. Qualitative semi-structured interviews were conducted with 15 Australian midwives who had at least 12 months of postgraduate clinical experience providing care to women giving birth in the last five years. Critical feminist theory underpinned each stage of the research, providing the theoretical lens to understand the nuances of gendered violence, power imbalance and institutional hegemony. Thematic analysis was used to analyse the transcribed in-depth interviews. Four key themes were developed from the data: 'the historical and situational context’, ‘the operationalisation of obstetric violence’, ‘the impact of obstetric violence’ and 'hope for the future'.Midwives discussed power imbalance, gender inequality, the impact of patriarchy and grooming for compliance as the enabling backdrop for OV. Continuity of care models were considered protective, though this was seen as limited within a fragmented maternity system. Midwives viewed OV as largely unchallenged in the maternity system. The 'tools of obstetric OV' described by midwives included coercion, unconsented and unnecessary interventions, and physical and emotional abuse. Midwives described the impact of witnessing or being complicit in OV, recognising that the trauma was not just experienced by women but also affected midwives themselves. Mistreatment of women in childbirth is gender-based violence enabled through patriarchal structures and power imbalances. Australian midwives are witnessing OV in both public and private maternity services. Most commonly, unconsented interventions, overmedicalisation, coercion and disrespect were observed by midwives with perpetrators being trusted HCPs. Midwives experience trauma as a result of their involvement or complicity in OV with little support provided when advocating for women. Further research is required to garner the perspectives of midwives, obstetricians, doulas, paediatricians and other birth workers in order to gain a more in-depth understanding of OV in Australian health care settings.

The use of cardiotocograph (CTG) monitoring technology is ubiquitous in highincome countries. Central fetal monitoring technology has made it possible to observe a birthing woman’s CTG outside her birth room. Research regarding CTG monitoring demonstrates no significant benefits for the baby and increased rates of surgical birth for women. Very little evidence specifically addresses central fetal monitoring. Despite claims that obstetrics is evidence-based, obstetric organisations continue to recommend CTG monitoring. My research took a critical feminist stance, questioning the relationships between obstetric power and central fetal monitoring. Using Institutional Ethnography, I examined how maternity clinicians’ intrapartum care provision was organised by, and in relation to, a central fetal monitoring system (K2) in an Australian maternity service. Four focus group interviews, 27 one-on-one interviews and 97 hours of observation were conducted. Relevant texts were also collected. Midwives described a troubling social event, which they named being K2ed. Obstetric or senior midwifery staff would come into the birth room without the midwife requesting their presence. The staff member entering the room was almost always responding to a CTG interpreted as abnormal when viewed at the central monitoring screen. Midwives experienced being K2ed as intrusive and disruptive. I defined this event as the problematic for my inquiry. Interviews and observations were transcribed, and along with texts, were indexed to identify and collate work processes, social relations and texts. Indexed data were analysed by questioning what they demonstrated about how being K2ed happened. The goal of analysis was to explicate the social and textual organisation of maternity clinicians’ work which made being K2ed possible. The structure of the K2 system shaped the nature of data entered into K2 and midwives’ documentation work. Midwives worked with K2 to build a representation of the birthing woman, make decisions about initiating CTG monitoring, generate an interpretable CTG recording, interpret the CTG and take action in response to abnormalities. Obstetricians and the midwifery team leader read the data in K2 at the central monitoring screen. Contextual information available to the midwife working with the birthing woman was not visible at the central monitor. The decision to use CTG monitoring increased the probability of being K2ed. This decision was usually made by the midwife and was strongly structured by a set of texts. These texts also shaped expectations of midwives’ work in generating an interpretable CTG, defined how to interpret the CTG and structured the actions taken when the CTG was categorised as abnormal. Tasks completed by obstetricians, such as fetal blood sampling, were not as strongly coordinated, leaving obstetricians with a degree of autonomy. Midwives were expected to escalate care to senior staff when the CTG was abnormal. This expectation supported being K2ed as a logical behaviour. If the clinician at the central monitor saw an abnormal CTG, and in the absence of contextual information to explain why escalation was not required, the clinician felt justified in going to the birth room when the midwife had not requested their presence. The Intrapartum Fetal Surveillance guideline produced by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists established the discursive territory for other policy texts relating to intrapartum fetal heart rate monitoring. Research regarding intrapartum CTG monitoring incorporated assumptions regarding birthing women (passive, risky), the fetus (precious, at risk) and midwives (lacking competence, needing supervision). These beliefs were translated from research into policy texts, the design of K2, and fetal monitoring education, and therefore entered the everyday work of midwives. Using Institutional Ethnography to generate a map of social relations, I demonstrate that obstetric ideology acted as a ruling relation, structuring midwives work and reinforcing obstetric dominance in maternity care. Patriarchal views embedded within the textual organisation of the workplace shaped the way that birthing women were knowable and how maternity clinicians acted in relation to that knowledge. Honest conversations within obstetrics and more widely in maternity care are required to acknowledge the harms currently occurring from the use of central fetal monitoring systems. I conclude by suggesting that it is time that maternity clinicians challenged obstetric ideology and focused on growing midwifery as a better model for the future.

Interprofessional education (IPE) has been found to improve patient outcomes and increase health practitioner career satisfaction according to The World Health Organization (2010). Despite these identified benefits arising from over thirty years of IPE research in a global context, there is still surprisingly little evidence with regard to how midwives develop their professional identity within the context of IPE. This study examined the interprofessional aspects of professional identity development for students and qualified clinicians in midwifery, including midwifery clinical educators and midwifery academics. This study utilised the theoretical framework of social constructionism. There were fifteen participants involved from three Australian universities, one hospital and one community setting. Using narrative inquiry as the methodology, stories were collected using in-depth interviews and a narrative approach. The individual stories were examined for revelations into the meanings drawn by each participant using a thematic analysis approach. Five themes emerged from the data. These were: shared misconceptions; shared understandings; shared misdirections; shared professional values; and shared misgivings. Then each story was examined for commonalities and differences of meaning drawn across all of the participants, congruent with Clandinin and Connelly’s (2000) narrative inquiry space (NIS) analytical approach of relational, temporal and spatial. From this interpretive analysis, a further lens was developed to more adequately present the interpretation of the participants’ narratives which could not be accommodated with the NIS. This resulted in the fourth element of ‘fluidity’ comprised of the influencers of ‘empowerment’, ‘competence’, ‘value’, and ‘respect.’ It is through the element of fluidity that the nascent nature of professional identity of the midwife in interprofessional education has been explored and presented. Thus, a theoretical understanding of the intersection between IPE and professional identity development in midwifery has been illuminated as a way to potentially enhance the efficacy of interprofessional practice, education and research. Moreover, the focus on student and registered midwives, both in the education sector and in the clinical environment is critical because, as the midwifery workforce, they are charged with the ongoing development of midwifery as a profession promoting improved patient outcomes, their own professional identity and interprofessional practice.

This thesis examines the ways in which early modern medical texts presented the mind-body connection as it impacted child-bearing women in seventeenth century England. The medieval rediscovery of ancient Greek medical knowledge dominated understandings of health and healing for centuries but reached its widest audiences with the explosion of vernacular language printed materials in the early modern period. Foundational to these repurposed ancient medical theories was the belief that the mind and body interacted in complex ways, requiring frequent monitoring of emotional states to achieve good health. For practitioners concerned with women’s reproductive health, women’s emotional regulation was vital to desirable physical outcomes throughout the period of childbearing, lasting beyond modern designations of conception and childbirth. Thus, this thesis challenges assumptions of how early modern historians should mark the phases of reproduction and argues instead that childbearing, at least for women, continued through the first years of an infant’s life.

Better outcomes for mother and baby observed in 'midwifery continuity of carer' programmes are attributed to positive midwife-woman relationships formed within these models, but this effect is not fully understood. Like midwife-led care, continuity of midwifery carer in Australia continues not to be seen as mainstream. To advocate for and better understand this continuity of carer model, this study used video ethnography framed by feminism and a critical approach. Midwife-woman interactions in a number of late pregnancy antenatal appointments were observed and filmed. These were at two Sydney hospitals with either the midwifery continuity of carer programme or in standard maternity care. Focus groups and interviews were undertaken. Thematic and content analysis techniques were used. Worry was a common feature of the antenatal appointment. It reflects the worry pregnant women report: worry about pregnancy, their baby, uncertainty about birth and transition to motherhood. 'Dysfunctional' or 'iatrogenic' worry occurred with system-focused midwives invested in standardised/medicalised tasks, whereas 'functional' worry occurred with woman-centred midwives invested in the woman. Hope creation was also seen, although less frequently. It occurred when worry was moderated and linked with adaptation of standardised and medicalised appointment factors, including environment, time, and midwife investment (how she interacted with the woman). Regardless of where they worked, some midwives were 'adaptive experts', but in most instances the midwives in continuity had greater opportunity to adapt. This adaptation resulted in midwife-woman interactions being bidirectional and shared, with discussing and storytelling taking place, rather than one-way midwife telling. These shared interactions created connection, or reflected the connection created by continuity of carer. This study showed the benefit of the midwifery continuity of carer programme. It provided opportunity for midwives to adapt, worry was moderated, and women appeared more hopeful. Being more hopeful may enable women to better manage their labours and parenting, creating these improved outcomes.

Background: The transition to motherhood can be difficult. For some women, it can be a distressing time, especially those who do not have social support. Studies indicate migrant women demonstrate higher levels of distress and perinatal depression. Migrant women primarily attribute their feelings and experiences to separation from family and usual support systems, financial hardship, poor working conditions and difficulties in adapting to life in a new country where traditions and culture are different. Experiences can also be affected by less-than-optimal care and poor engagement with health services. Most research on migrant mothers has been conducted among those living in high-income countries, with few studies of women who begin their lives as mothers having migrated from a low-income country to another low-income country or middle-income country. Recently, there has been a dramatic increase in the number of migrant workers coming from Burma to Thailand; over time, many become parents. However, little is known about their experience of motherhood and perceptions of maternity services. Understanding the experiences and challenges that Burmese women encounter when seeking maternity care in Thailand is important because receiving inadequate care is linked to increased rates of morbidity and mortality. Study aims: This study aimed to explore Burmese migrant women’s perceptions of becoming a mother and their health care and support needs. It also aimed to examine their perceptions of maternity services, including access to and use of Burmese interpreters. The research also examined the experiences of Burmese interpreters and Thai health professionals caring for Burmese migrant women. The social-ecological model is used as a framework to conceptualise the multiple factors influencing the experiences of Burmese women and to identify implications for service delivery. Methods: Ethnography informed the study design. Between May and December 2015, data were gathered through individual interviews with three participant groups. These included 10 Burmese migrant women, four Burmese interpreters and nine Thai health professionals. Observations of the interactions among participants of the study occurred in two antenatal and postnatal settings in Ranong, southern Thailand. General observations of the activities and interactions in the clinics were also conducted in the villages of some participants. The data were analysed using thematic analysis. Results: All women in this study who migrated to Thailand came for employment and all held legal status with a work permit. They lived in a tight Burmese community but their living and working conditions were difficult. Becoming a mother was important to them; however, they had to juggle work and care for young children. Most realised that once their child was school age, the children would be sent to Burma to live with relatives. The women valued Thai antenatal care, but they combined this with traditional practices, particularly cultural practices, that they believed would protect their baby in pregnancy and after birth. Due to poverty, many women could not afford a nutritious diet and were at risk of gestational diabetes and anaemia. The women were well supported by their families and social networks during pregnancy and following the birth of their babies. Although Thai health professionals spoke positively about the Burmese women they cared for, they were also critical of certain cultural practices and became irritated when Burmese women did not follow their advice (e.g., taking iron and folate, and agreeing to sterilisation once they had two children). The theme ‘being processed’ captured the numerous barriers to accessing antenatal care while ‘being cared for’ provided insights into the care and support from professionals that women found helpful. The final results chapter examines the role and experiences of Burmese interpreters (lam in Thai) identifying their dual role as interpreter and healthcare worker. Key challenges included lack of clarity around role boundaries and low remuneration. Implications: The findings contribute to a conceptual understanding of Burmese migrant mothers in their journey towards motherhood. Participants, including the interpreters, indicated that they required service providers to be culturally competent and compassionate. The findings could be used to guide Thai nurse-midwives and other health providers in providing care for migrant women. Health care provision in Thailand needs to be supplemented by an understanding and awareness of the needs of migrant women. This is particularly important to facilitate health services for migrant women, who are in unstable circumstances and have to balance their responsibilities as mothers and migrant workers.

Background: Midwifery Group Practice (MGP) is a service where women are cared for by one primary midwife, supported by another midwife or group of midwives, who work in partnership with them across all stages of the pregnancy, birth and postnatal period, within the public hospital system. MGP outcomes consistently show reduced medical interventions and high levels of satisfaction for women yet only 8% of women in Australia have access to this option of care. Midwives working in MGP are shown to display a higher job satisfaction and occupational autonomy compared to midwives providing standard hospital care. Management of services is closely aligned with staff retention and satisfaction and so is critical to MGP sustainability. Since little is known about the attributes of a manager for effective management of these services, this research is urgently needed to help ensure these models of care are sustainable. Aims: The aim of this project was to discover the attributes required in a manager of a MGP in Australia in order to effectively manage the service. Methodology: A qualitative approach using thematic analysis was used in this study. Eight midwifery leaders were purposively sampled and interviewed ace-to-face using semi-structured open-ended questions. The interviews were audio-taped and transcribed for analysis. Findings: The overarching theme ‘Holding the ground for midwifery, for women’, described the role of the MGP manager as someone who stands up for midwives and women. Three themes demonstrate the complexity of the role of the manager and the intrinsic traits that make an effective leader, described as ‘having it’, the actual job of management captured under the theme ‘someone with their hand on the steering wheel’ and the job of ‘juggling forces’ that surround MGP. The theme ‘Helping managers to manage better’ describes the preparation for the role and the support required to help the manager in this demanding position. Conclusion: The findings of this study will contribute to knowledge about what is required for effective MGP management to help enhance sustainability of these services and how best to prepare the managers for this role. Development of effective management and leadership styles could contribute to adopting a healthy, progressive culture within the hospital hierarchy. It is hoped this study will contribute to further research into midwifery management, MGP sustainability and barriers to MGP.

Abstract: Background: The increasing trend in global neonatal deaths over the past decade has engaged global, regional, and national communities in seeking sustainable approaches to improve neonatal health outcomes. The major causes of these deaths are preterm birth complications, intra-partum related complications (including birth asphyxia), and sepsis. Understanding the dynamic contextual factors underlying these neonatal deaths are important to inform priorities for improving newborn health outcomes in the new Sustainable Development Goal [SDG] 2015-2030 era. Birth asphyxia, a preventable respiratory emergency that leaves survivors with irreversible neuro-muscular deficits, is associated with the quality of antenatal and intra-partum care. The worst affected are people who reside in rural communities within Sub-Saharan Africa where inequitable health coverage predominantly influences survival. In low-and-middle income countries [LMICs], very little information exists on care experiences of midwives regarding birth asphyxia. However, midwives have developed rich experiences in maternal and newborn health as frontline health workers. Predominant factors related to the occurrence of birth asphyxia include lack of access to basic and comprehensive emergency obstetric and newborn care, shortage of skilled staff, lack of basic life-saving devices, care provider inadequacies and poor referral systems. Aim: To understand, unveil the meanings and articulate the experiences of midwives who are faced with newborns affected by birth asphyxia in rural birth settings within southern Ghana. Methodology: Interpretive phenomenology that incorporates Heideggerian philosophy was used to explore, unveil the meanings and articulate the experiences of midwives who faced newborns with asphyxia at birth. Thirteen midwives were purposively sampled from rural birth settings in Southern Ghana (Shai-Osudoku District). Data were generated through audio-recorded conversations (voice text) with the midwives, field notes, and reflective journal. Emerging themes were synthesized from the oral data, verbal transcripts, field notes, reflective journal and commentaries from two second readers to produce detailed understandings of the midwives’ experiences. Emerging themes produced a rich understanding of midwives’ embodied experiences as they faced newborns with birth asphyxia. Findings: Rural midwifery practice in Ghana is grounded in harmonious communal relationships within restricted health care spaces where silent suffering occur. Midwives experience emotional drowning and adopt spirituality as coping mechanism when faced with birth-asphyxiated newborns. Midwives encounter moral distress and situation-helplessness within hegemonic power structures. Newly qualified midwives practice without mentorship in unsafe clinical spaces where ethical questions emerge as family members assist in resuscitative procedures. Conclusion: New knowledge serves as basis for scaling up practices, directing capacity building strategies, developing policies and implementing research-informed interventions to support midwifery practice, prevent birth asphyxia and improve newborn health outcomes in rural Ghana

In 2005, Ethiopia enacted a rare reform, liberalizing abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries. However, few countries have reformed their laws to permit safer, legal abortion, and medical associations typically avoid reform advocacy. The three studies presented in this dissertation examine the political origins and theoretical implications of this unusual reform in Ethiopia, as well as the roles of health providers and their medical societies in reform and implementation. The first study describes the political history of the reform and assesses the utility of theories of agenda setting. The second study explores why, counter to theoretical expectations and empirical accounts, a medical society actively supported reform of national law on abortion. Finally, as laws in resource-poor countries are often weakly implemented, the last study looks at midwives' roles in implementation by assessing what underlies their decisions about abortion service provision. Data for the three studies are drawn primarily from fifty-four interviews conducted in 2012 with obstetrician-gynecologists and governmental and non-governmental actors involved in, or familiar with, Ethiopia's reform. The other data sources were a 2013 survey of midwives (n=188) at a national professional meeting and 12 interviews with third-year midwifery students. The first study finds that the liberalization of the law on abortion was facilitated by the ruling party and its receptiveness to reform, civil society actors collaborating closely with government, the "open windows" offered by the vehicle of the Penal Code reform and the momentum of reforms to improve women's status. This suggests that agenda setting theories focusing on national rather than international actors conform better to Ethiopia's reform process. The unusual medical society participation in the reform process was motivated by obstetrician-gynecologists' personal and organizational commitments to reducing maternal mortality as well as organizational and political circumstances that relaxed or removed constraints on policy involvement. The study of midwives' attitudes about implementing reform found that most (72%) were willing or possibly willing to provide abortion services, and that this willingness was positively related to attitudes toward abortion, knowledge of the law and past provision of medication abortion. Willingness to provide services was negatively related to their number of years as a midwife and religiosity. Interview data suggest complex dynamics underlying these results, including conflict between strong professional norms and personal religious beliefs. These findings can deepen our knowledge of policy-making processes in Sub-Saharan Africa and give insight into how medical professionals participate and understand their roles in policy making and in implementing controversial health policies.

The purpose of this study was to develop a substantive theory of the processes used by midwives in exercising their scope of practice when caring for women and babies during normal birthing. The grounded theory approach of Strauss and Corbin (Corbin & Strauss, 2008; Strauss & Corbin, 1998, 1990) was employed to inform data collection and analysis, including the use of participant observation and in-depth interviews with seventeen midwives practising in a hospital maternity unit. From this approach, the core category of Promoting normal birthing: Aspiring to develop a midwife-led scope of practice emerged, illustrating the processes utilised by midwives in practice to support normal birth.

This dissertation analyzes interactions between politicians, bureaucrats and diverse groups of women over the issue of maternity legislation in Norway between 1880 and 1940. It adds to a rich historiographic debate on welfare state development, women's roles in the creation of welfare policies, the Scandinavian model of welfare and the institutionalization of women's birth experiences. During the sixty years that this study encompasses, Norwegian maternity legislation underwent drastic and dynamic changes. From their initial implementation in 1892, maternity policies expanded in coverage, application and protections. This dissertation traces the history of this development along several lines, including local and national political processes and women's collective and individual influence. While women's access to maternity provisions steadily increased during this period, these achievements were fraught with struggles. Historical context shaped the types of arguments women could use to advance political debates about maternity. In many cases, these hindrances led to the creation of policies that promoted maternity legislation at the expense of certain groups of women's autonomy. Women did not act as a monolithic group when it came to maternity policies. Feminists, midwives and working women actively participated in the creation of Norwegian maternity policies and adapted them to fit their particular needs and interests. These groups of women transformed maternity leave from a mandatory, restrictive form of state control over women's reproduction to a benefit that all working women had a right to receive. In order to achieve more beneficial maternity policies, these groups of women embraced arguments that resonated with contemporary concerns. Late-nineteenth factory legislation had established maternity as an area of state intervention mainly because it fell in line with what other more industrialized countries were doing at the time. These early maternity policies restricted mothers' economic activities and women responded by demanding significant changes to maternity legislation. During the early twentieth century feminists and midwives, in particular, used the political focus on infant mortality rates and public health to push for compensatory maternity benefits for women. This led to more comprehensive maternity policies for working-class women. In 1913 Norwegian women won the right to vote, and during the interwar period feminists used women's new status as full citizens to frame maternity as an issue of women's rights. These efforts led to the passage of comprehensive and generous policies in the 1930s. The rhetorical framework that women constructed in order to achieve these results had a lasting impact on the development of maternity policy in Norway long into the postwar period.

The importance of early identification of women with psychosocial risk factors, such as child sexual abuse, substance use and domestic violence during pregnancy and after birth has gained significant recognition both nationally and internationally. Policy and guidelines, such as the Supporting Families Early (SFE) package in New South Wales (NSW), Australia, have been developed and recommend that psychosocial assessment be conducted by midwives and child and family health nurses (CFHNs). The purpose of this ethnographic, qualitative study is to examine and understand the meaning midwives, CFHNs and women make of the process of psychosocial assessment and depression screening undertaken during pregnancy and following birth. Specifically, this study describes and examines how midwives and CFHNs approach and deliver the psychosocial assessment questions; and their experiences and perceptions of the assessment process. This study sought to understand women’s experience of being asked the assessment questions. Thirty four women, 18 midwives and 13 CFHNs participated in this study. Participants were recruited from two different settings in NSW, Australia. Data were collected through observations of the interactions between the women, midwives and CFHNs during assessment and screening. An observation tool (4D and 4R) and field notes were used to record observations of the assessment and screening process. Following the observations, face to face interviews were conducted with the women, midwives and CFHNs. Approximately 60 Midwives and 70 CFHNs also agreed to participate in discussion groups, reflecting on their experiences and perceptions of the assessment and screening process. The findings presented in this thesis, including three published papers, demonstrate that midwives and CFHNs in this study experience tensions in conducting assessments, which may influence how questions are delivered. A flexible approach to assessment was preferred whilst incorporating structured tools into the process, however, some of the CFHNs in this study rejected the use of structured tools. A relationship based approach was common, developing rapport with the women to establish comfort prior to asking psychosocial assessment questions. Midwives and CFHNs utilised other skills such as observation, and drawn upon to inform their clinical judgement as to a woman’s propensity to be at risk of social and emotional distress. The tensions midwives and CFHNs experienced conducting assessment may be partially explained by the varying interpretations of the NSW SFE policy recommendations. Overall, the women perceived the assessment questions were important, however, some women experienced discomfort, surprise and felt unprepared to be asked these questions. Women who disclosed previous negative life events, such as child sexual abuse were distressed by this experience and appeared to comply with the assessment process. In this study partners who attended the clinic with the participating women were excluded from part of or the entire visit. Women reported in interviews, that their partners had a sense of what was being discussed in their absence and provided support to women who were distressed following disclosure. Effective delivery of assessment and screening requires ongoing education, training and supervision in the use of structured tools and how to best incorporate these into a relationship-based approach. Women could be better prepared prior to the assessment and may experience less distress if their midwife or CFHN responds with sensitivity and care. This study is part of a larger study funded by an Australian Research Council (ARC) linkage grant, in partnership with Karitane and was completed by me on a full time scholarship over three years. This thesis is presented as a series of four publications.

The problems caused by the worldwide nursing shortage, generally negative workplace experiences and deficits in health and wellbeing are recognised aspects of nursing and midwifery in the contemporary nursing workplace. The deleterious effects causing many nurses and midwives to become disillusioned and dissatisfied with the realities of nursing work are attributed to workplace adversity. Low retention rates have been a characteristic of the nursing and midwifery workforce for some time. The necessity of exploring additional ways of halting the harsh effects of workplace adversity by developing, strengthening and maintaining personal resilience has instigated the current study.

Pregnancy and the postpartum are critical stages in women’s adjustment to motherhood and can have a significant impact on childbearing women’s overall psychological well-being (Chokka, 2002; Stocky & Lynch, 2000). According to the National Midwifery Guidelines for Consultation and Referral (ANMC, 2006), the physical, emotional, social and cultural aspects for both women and their infant(s) need to be addressed as part of best practice standards in maternity care. To accomplish this, midwives need to be well-educated, competent and resourced in these areas of practice. Midwives are reported to provide poor intrapartum and postpartum emotional care to childbearing women that could in part, be attributed to low self-efficacy and knowledge inadequacies in regards to the provision of emotional care (Brown, Davey & Bruinsma, 2005; Bruinsma, Brown, & Davey, 2003; Gamble, Creedy, & Moyle, 2004b; Rudman, El-Khouri, & Waldenström, 2007a, 2007b). However, very few studies have been undertaken to both determine and improve Australian midwives’ knowledge of emotional care issues and address their professional development needs (Eden, 1989; Buist et al., 2006). Therefore, the aims of this research study were to: 1. Determine knowledge levels, attitudes and self-reported practices of midwives in relation to emotional disorders (i.e. antenatal and postnatal depression and anxiety disorders) during pregnancy and postpartum. 2. Develop, implement and evaluate an educational resource to improve the knowledge, attitudes and practices of midwives in the provision of emotional care. In addressing these aims, two research phases were undertaken. The first phase was a scoping study in the form of a national survey to examine midwives’ knowledge of perinatal emotional disorders and their attitudes and self-reported practices in providing emotional care to childbearing women. Information gathered from the first phase informed the development of an online educational resource designed to enhance midwives’ knowledge and abilities in this neglected area of midwifery practice so as to improve childbearing women’s emotional health needs and overall well-being. Thus, the second phase was to examine the efficacy of this online educational resource which was piloted and evaluated with a small group of Master of Midwifery students. Results of the national survey identified that midwives acknowledged their role in the provision of emotional care and support to childbearing women with perinatal emotional disorders. However, knowledge deficits in relation to incidence rate, onset period, assessment and treatment options for both antenatal and postnatal depression as well as the use of the Edinburgh Postnatal Depression Scale in practice were also highlighted. Results from the Phase 2 study suggested that the online educational resource was useful in improving midwives’ knowledge of perinatal emotional disorders. Nevertheless, revisions are needed to further enhance the overall quality of the online educational resource with emphasis given to the translation of knowledge into practice and improving midwives’ self-efficacy in emotional care work. In view of the increasing importance on the provision of emotional care to childbearing women, it is essential that midwives develop their knowledge and understanding of perinatal emotional disorders and ways to assess and manage childbearing women affected by these disorders in order to provide better support and emotional care.

Midwifery in Thailand has long been established, and midwifery practice has been provided in five health care setting levels (primary to tertiary). In this country every registered nurse also becomes a licensed midwife at initial registration. In the current research of exploring current midwifery practice in Thailand, the randomly selected samples comprised 3,030 nurse-midwives whose work involve with pregnancy care in all levels of health settings across the country. In the study the questionnaire was used as a tool to collect data of demographic data and midwifery practice of nurse-midwives providing to pregnant women. One of interesting findings revealed that only 44 (1.5%) of 1,511 respondents (50%) identified themselves as midwives. Almost of the respondents identified themselves as obstetric nurses. This less identification of a midwife is of great interest as all respondents are those who work with pregnant women. In terms of midwifery profession, it is accepted that once one graduates and receives a midwifery license, and provides care for pregnant women should be called “a midwife”. Not identifying as a midwife simply implies that midwifery profession in Thailand is standing in a week position. To develop midwifery profession, it seems essential that the professional members must firstly recognize their own professional identity by claiming themselves as a midwife. However, before implementation of developing strategies, it is important that respondents' perceptions on the term they prefer and do not prefer to be called are explored. The purpose of this paper is to present the further findings of how the respondents feel about the terms “midwife”, “professional nurse”, “nurse- midwife”, and why they identified/not identify themselves as midwives though they work with pregnant women. The widely scattered locations of the volunteers resulted in a difficulty in forming the planned discussion groups as the anticipated number of participants (four to six) could not be achieved due to the location of the participants. Therefore, individually interviews were conducted in the areas. Differences in environment and approaches might have affected the responses of participants and could affect the findings.

This thesis develops an approach to midwifery that is more open to the (un)known, to the (un)thought, to the (im)possible. It argues for practitioners who have an ethical responsibility to embrace difference and to welcome the other. In this thesis I write of ways midwives and others ‘word the world’ and act in it, in order to understand how midwives can and do embrace opening themselves to possibilities and difference, in order that childbearing women will not have their possibilities for personhood closed. As a midwife and a midwife-academic, I ask how current discursive practices in midwifery and childbearing function as they do. Using the techniques of ‘writing as inquiry’ and genealogy I bring to the foreground ways in which midwives think and act with and against the grain in the maternity health care system. Interrogating overlapping and competing discourses in midwifery, I work to understand how discourses produce at the same time numerous identities and accompanying ambivalence. In seeking understandings of the work that women do to constitute themselves as midwives, I write of midwives’ political and ethical moves towards and away from difference and towards and away from sameness, rules and order. While midwifery does not generally recognise itself in poststructuralism, midwifery is (sometimes often) a poststructural practice. As I spotlight moments in which midwives already move in poststructural ways, I argue that a serious reflexive turn for midwives towards poststructural theory and practice is easily imaginable, and desirable. The thesis argues that theories and practices which help midwifery move closer to the (un)known, the (un)thought, the (im)possible are ethically and politically responsible. In embracing difference and welcoming the other, childbearing women and midwives together may create their best chances yet for viable mothering and midwifery lives. This is the ‘possibilities work’ midwives and midwife-academics can do.

Balochistan, the largest Province in Pakistan, where more than ninety percent of births are attended by traditional midwives- outside of hospitals-functions as a site whose geography and population are racialized across multiple scales in colonial and postcolonial Pakistani state discourses. It is part of a region economically marginalized and divided between Pakistan, Iran, and Afghanistan. Through an ethnography of local medical practices and national development policies and analysis of discourses operating across these different scales, I address the relations between local midwives' practices, their knowledge about reproductive health and plant medicines and the historical and contemporary policy construction of their identities and social worth in the context of a multi-ethnic society. I examine political technologies of intervention to deconstruct the mechanisms by which the contemporary marginalized group of healers (local midwives), Balochi medicine, and Balochistan is represented through gender and racialized terms of 'backward tribes'. In particular, I address how colonial medical practices and present flows of scientific knowledge informing biomedical and health development agendas intersect to influence contemporary power structures and the medicalization of the social body in Pakistan. I elucidate the latter context and link it to delineate how this impacts healing practices in Pakistan, shaping and constituting dais' (midwives) work and the production of dais' and biomedical practitioners' identities. Principally, I argue that epistemological and material violence are inseparable. That is, the discourses about "traditional birth attendants" enable a type of invisible violence against both them and the large number of women in Pakistan who rely on them. I argue that the conditional inclusion of local midwives is the violence that restructures social relations outside of the bio-medical context such that while the aim is to advance women's health, in fact it often damages it by producing new and reinforcing old hierarchical structures. Informed by a vast and multi-dimensional archive including ethnographic research comprising: interviews with local midwives, childbearing women, biomedical practitioners, policymakers, and government officials; archival research of organizational documents; print media; and the existing and historical literature on reproductive health and midwives, my research contributes to the understanding of an understudied region and people.

The dissertation examines the Guatemalan Ministry of Health's attempts to lower maternal mortality among Kaqchikel Mayan women in Solola. It is argued that the roots of the campaign, which can be found in the international Safe Motherhood Initiative, assume a certain independent actor as the recipient of their policies. Through an analysis of birthing in the village, it is argued that this subjectivity is actually not dominant among Kaqchikel villagers. Nevertheless, local health workers, many of whom are Mayan themselves enthusiastically push the Safe Motherhood agenda. This effort is interpreted as personal attempts to construct a unified nation in a divided, post-civil war society. The argument is presented in four different sections. Section one, the introduction, consists of a prologue and situates the theoretical importance of the research within broader anthropological inquiry and more specifically in the domain of studies of reproduction and maternal mortality. Section two establishes the context of the research, both providing a background of the international and national battle against maternal mortality as well as a description of the ethnographic setting. Section Three addresses obstetric emergencies from the perspective of Kaqchikel villagers. The perceived failure of women to access hospital resources for emergencies is discussed. Section four concentrates on the hospital setting itself and addresses what happens when women go to the hospital. It also interrogates ideas of culture and knowledge bound together in the local practice of medicine. The data analyzed was collected over two years of field work and consists of interviews, participant-observation, observation and recordings made in the ER of women with obstetric emergencies.

This study was conducted in the context of the regulation of professional nursing and midwifery practice in the Australian health care system. In this environment, professional regulatory authorities established by State and Territory legislation in all jurisdictions, regulate and control the work of health professionals. In Queensland, registered nurses, enrolled nurses and midwives are regulated by the Queensland Nursing Council, the statutory body created by the Nursing Act 1992 (Qld). Part of the regulatory role of this and other authorities is to discipline professionals whose conduct or behaviour falls short of appropriate and acceptable standards of practice. All regulated health professionals, including nurses and midwives, are potentially subject to professional disciplinary action if a complaint is lodged in relation to their conduct. This being an important issue in the management and delivery of health care, and an increased trend among health care consumers, the dearth of existing research into the disciplinary process is a major concern. This exploratory study examined the disciplinary role of the Queensland Nursing Council in adhering to its legislative mandate to ensure safe and competent nursing practice. The study focused on the extent to which structural (legislation and policy), professional, and process factors impacted on the outcomes of disciplinary Tribunals and Committees in cases of incompetent or unsafe practice and sexual misconduct. The study was situated within the interpretive paradigm using a case study approach. Specifically, it investigated cases of sexual misconduct by nurses and unsafe or incompetent practice by midwives. The study was guided by Donabedian's conceptual framework of structure-process-outcome. This framework was seen to be most suited to the aims of the study and provided a template for in-depth analysis of the data emerging from the two cases. The findings of this study provided insight into the factors underpinning the decisions of the disciplinary bodies in making determinations and formulating outcomes. There was found to be a lack of consistency and predictability in both the legislative frameworks and the interpretation of terms and concepts used to identify conduct warranting a disciplinary response from regulatory authorities. Although the processes of disciplinary proceedings are prescribed by both legislation and policy, their practical application was characterised by considerable challenges, which resulted in varying outcomes. The thesis reports this information so that it can be used as an initial basis to build a body of knowledge from practical experience with disciplinary proceedings that will inform future processes. Subsequent case studies in other contexts and systems will increase the level of knowledge available to nurses, other health care providers, health care institutions and regulatory authorities. The initial base of evidence suggests implications for practice, education and further research which are outlined in the final chapter of the thesis.

This study explored the meaning of the phenomenon of the midwife's experience of being present with a woman during childbirth. The value and importance of being with a woman during childbirth, specific and unique to midwifery care, is reflected in midwifery philosophies and models of care. This study looked through the lens of midwives who have written poetry about births they have attended to learn more about the experience of being with a woman. Hermeneutical phenomenology was selected for the philosophical methodology and method because it looked at both the phenomenon and the use of language to describe the phenomenon. The researcher reflected upon and interpreted 18 selected poems as data and developed themes, which described the midwives, lived experiences of being with a woman. The data revealed that being with a woman was a key phenomenon that permeated all the themes developed from the interpretation of the poetry, spiritual connections, experienced guidance and partners in birth. Themes consisted of midwife actions or beliefs, or both about the phenomenon. The researcher also discovered three authoritative ways of knowing that guided the amount of presence the midwife provided to women during childbirth. They were self-knowledge from the belief system of the individual midwife, grounded knowledge through personal lived experience with childbirth, and informed knowledge from objective and scholarly sources. Themes from the poetry that were supported by midwifery models of care and informed knowledge such as safety and protection were also valued by the dominant medical paradigm as legitimate knowledge. Themes from the poetry that were supported through effective knowing such as handwork and succoring connections were important to recipients of midwifery care and considered legitimate knowledge in personal narratives and stories written by midwives. This study found that being with a woman during childbirth is an important aspect of midwifery care. Certain aspects of being with woman such as the midwife's connection to and use of spirituality and the use of touch require further inquiry. Midwives need to support midwifery knowledge as a legitimate form of knowing and being with woman as a legitimate form of caring in the provision of care to women.

Childbirth can be associated with short and long-term psychological morbidity including depression, anxiety and trauma symptoms. Some previous studies have used psychological interventions to reduce postpartum distress but have primarily focussed on attempting to relieve symptoms of depression with little recognition of trauma symptoms. Furthermore, the intervention used in these studies has generally been poorly documented. The first aim of the present study was to develop a counselling framework, suitable for use by midwives, to address psychological trauma following childbirth. Multiple methods were used to develop the intervention including focus groups with women and midwives. Both the women and midwives gave unequivocal support for postpartum debriefing. Themes that emerged from the focus groups with women included the need for opportunities to talk about their birth experience, an explanation of events, an exploration of alternative courses of action that may have resulted in a different birth experience, talking about their feelings such as loss, fear, anger and self-blame, discussing social support, and discussing possible future childbearing. There was a high level of agreement between the women's and midwives' views. These themes were synthesized with contemporary literature describing counselling interventions to assist in reconciling a distressing birth experience and a model for understanding women's distressing birth experiences to develop a counselling framework. The counselling intervention was then tested using a randomised controlled study involving 400 women recruited from antenatal clinics of three public hospitals. When interviewed within seventy-two hours of birth, 103 women reported a distressing birth experience and were then randomised into either the treatment or control group. Women in the intervention group had the opportunity to debrief at the initial postpartum interview (< 72 hours postpartum) and at four to six weeks postpartum. The prevalence of posttraumatic stress disorder was quite high; 9.6% of participants meeting the diagnostic criteria for acute PTSD at four to six weeks postpartum. Fewer participants (3.5%) met the diagnostic criteria for chronic PTSD at three months postpartum. As with previous research relating to childbearing women, few demographic factors or antenatal psychological factors were associated with the development of a PTSD symptom profile following childbirth. The development of PTSD symptom profile was strongly associated with obstetric intervention and a perception of poor care in labour. This finding is also consistent with previous research. Emotional distress was reduced for women in the intervention group in relation to the number of PTSD symptoms [t (101) = 2.144, p = .035], depression [c2 (1) = 9.188, p = .002], stress [c2 (1) = 4.478, p = .029] and feelings of self-blame [t (101) = -12.424, p

In this study, the childbearing women's perception of the role of a midwife in Australia was explored using a descriptive study. Data was gathered using a semi structured questionnaire.The findings revealed that childbearing women in Australia overwhelmingly believed a midwife is specifically trained and qualified to deliver babies normally and to care for a woman in labour.In addition, the belief was that a midwife is trained to provide a comprehensive range of maternity related tasks.The overriding themes which emerged identified the midwife as a source of advice, information, support, education, guidance, specific midwifery knowledge and being a liason person between the doctor and the pregnant woman.Limitation of the role of a midwife was believed to be due to the nursing based training of a midwife.The findings from this study revealed that childbearing women in Australia, United Kingdom and Singapore have similar perceptions of a midwife's role.Recommendations were made for further studies to investigate the reasons for a persistent lack of information regarding the role of a midwife and the type of information required by pregnant women.

The primary aim of this research is to compare the charges incurred by the productions processes used by each of two providers of maternity care, certified nurse-midwives (CNMs) and obstetricians (OBs) while controlling for risk status at the beginning of pregnancy. The second aim is to determine whether the charges associated with maternity care are influenced by provider group or by consumer preferences. Subjects for the study are 505 women who enroll in either the Nurse-Midwifery Service (33%) or women of equal risk status who select obstetricians (66%) in private practice at a tertiary medical center. Comprehensive charge data were collected from hospital billing records and from professional service charge records. In this setting the fee for care is the same whether it was delivered by a CNM or by an OB. Consumer preferences were determined from questionnaire data completed approximately 6 weeks before the anticipated birth of the infant. Results showed that CNM charges were almost 17% ($1,460) less per case than the charges of OBs. The hospital charges of CNM clients were almost 21\% (\$1,112) less than the hospital charges of the OBs with a lesser savings (10% or $348) in professional service fees. There were no significant differences between OBs and CNMs in the baby charges. The results of this study indicate that CNM clients did have preferences which were significantly different from the obstetrician patients on four measures of practice. OB patients were more likely to definitely want ultrasound, pain medication in labor, electronic fetal monitoring, and the use of stirrups. However, provider group was found to be a stronger predictor of charges than were consumer preferences. If the cost savings found in this setting at today's prices were applied nationally to the 70% of women who meet the low to moderate risk criteria of the nurse-midwifery service, an annual savings of over $4 billion could be realized.

This study is an exploratory study, descriptive in nature and investigates the familiarity and practices of midwives and women with regard to complementary therapies during pregnancy and labour. The study was conducted in four major hospitals in Western Sydney, namely Nepean, Jamieson, Blue Mountains Anzac Memorial and Hawkesbury hospitals. The findings showed that in the main the midwives and women were familiar and made use of four therapies, ie. aromatherapy, massage, music and hydrotherapy. The midwives practiced without any significant training in these therapies. Hospital policies were almost non existant in relation to the practice of complementary therapies and nurses often felt frustrated at not being able to implement complementary therapies. The main issues that emerged from the study were the need for education for the midwives related to specific complementary therapies, hospital policies conducive to the practice of complementary therapies and research into the efficacy of the different complementary therapies. The women need further exposure to complementary therapies and education in the respective therapies if they are to feel empowered in dealing with the stress of their daily lives