PLOS GLOBAL PUBLIC HEALTH
Research Article
Hearing the voices of midwives through reflective writing journals: Qualitative research on an educational intervention for Respectful Maternity Care in Zimbabwe
by Sunanda Ray, Christina Mudokwenvu-Rawdon, Myriam Bonduelle, Ginny Iliff, Caroline Maposhere, Priscilla Mataure, Cecilia Jacobs, Susan C Van Schalkwyk
Abstract
Women attending public and private sector health facilities in Africa have reported abuse and neglect during childbirth, which carries a risk of poor health outcomes. We explored from the midwives’ perspective the influence of an educational intervention in changing the attitudes, behaviour and practices of a group of midwives in Zimbabwe, using transformative learning theory as the conceptual framework. The twelve-week educational intervention motivating for Respectful Maternity Care consisted of a two-day workshop and five follow-up sessions every two weeks. Thematic analysis was conducted on eighteen reflective journals written by the midwives with member-checking during follow-up discussions and a further one-day participative workshop a year later. The midwives reported being more women-centred, with involvement of birth companions and use of different labour positions, stronger professional pride and agency, collaborative decision-making and less hierarchical relationships, which persisted over the year. Their journal narratives included examples of treating birthing women with more compassion. Some categories aligned with the phases of transformative learning theory (self-examination of prior experience, building of competence and self-confidence into new roles and relationships). Others related to improving communications and effective teamwork, providing role-models of good behaviour, use of scientific knowledge to inform practice and demonstrating competence in management of complex cases. This study shows that innovative educational initiatives have the potential to change the way midwives work together, even in challenging physical environments, leading to a shared vision for the quality of service they want to provide, to improve health outcomes and to develop life-long learning skills.
Introduction
Women in public and private sector maternity services in Africa have reported a wide range of physical and emotional abuse and neglect from health professionals (including midwives) in well-resourced and poorly-resourced settings [1–12] including in Zimbabwe [13]. The consequences of scolding and controlling approaches towards women in labour include poor obstetric outcomes such as delayed progress in labour, higher risk of instrumental and surgical interventions and postnatal depression, and are often unrecognised [14,15]. The dissonance between midwives’ professional pride and their apparently disrespectful behaviour in their workplaces creates tensions between them and the women in their care. Negative birth experiences may deter women from seeking institutional care during labour, whereas increasing rates of skilled birth attendance and facility-based childbirth are considered vital to reducing maternal morbidity and mortality [2,3,9,11,12].
A review of relevant literature, documents and interviews identified seven categories of disrespect and abuse in childbirth: physical abuse; non-consented care; non-confidential care; non-dignified care; discrimination based on specific patient attributes; and abandonment of care and detention in facilities [11]. These categories of abuse have been found from research in health facilities in African countries to be more widespread than anticipated, dispelling the notion that acts of abuse are isolated events carried out by “bad apple” individuals [1,2,4,5,8,11]. The failure of authorities to trigger disciplinary action in response to abusive activities has “normalised” such behavior especially in the eyes of health staff and is an indicator of health system weaknesses and failure of accountability [3,4,8,9]. The missing voices of midwives in research on abuse of women in childbirth has resulted in lower appreciation of the work constraints within which most midwives’ behaviour is embedded, which some argue constitutes disrespect for midwives themselves [15].
Research from African countries has shown that complex relationships between midwives and birthing women give rise to dissonance in the professional identity of midwives [8,9]. Midwives are expected as professionals to be altruistic, caring and to put the interests of women in their care first, but instead may demonstrate disrespectful behavior. They may purposefully use abuse to create social distance between themselves and birthing women, based on their perceptions of class, power, identity and knowledge superiority, as a protective strategy to avoid engagement and to preserve the power differential between them [8,9,16]. Professional ethics that champion women’s rights to information and autonomy could appear threatening to midwives in this context [8]. Medicalization of childbirth, with its emphasis on technology and pharmacological interventions, gives midwives control with rules and discipline over the experience of childbirth, rather than allowing women to have autonomy, to take positions they are comfortable in or by having companions to support them [6,15]. Some midwives who may be fearful of being blamed for poor outcomes, attempted to control women during childbirth, including by punishing them for disobedience with physical abuse [15,17].
This disrespect, neglect and abuse has been termed obstetric violence by some authors [14,17,18]. During institutional births, especially in low-resource settings, women may be left to give birth alone and are vulnerable without companions who could mediate for them and provide support [6,7]. Continuous practical and emotional support from birth companions during childbirth is associated with positive experiences and improved outcomes for pregnant women and their partners [14,19].
Abusive behaviour towards birthing women has mainly been studied using exit interviews and focus group discussions with service users and less commonly, with providers [1,2,10,11,15]. Various interventions have been proposed to motivate for more respectful behaviour. These include stronger nursing leadership, professional accountability, training to promote respect for patient autonomy, better adherence to codes of ethical practice, quality improvement initiatives, inclusion of birth companions and creating confidential complaints procedures that will not lead to patient victimizations. [1,7,8,11]. The legacies that have shaped health systems, the models of car4e and training, cultural norms within which they have developed, and the perspectives of midwives requite greater scrutiny. Enabling midwives and pregnant women to develop greater agency and advocacy skills, despite being apparent victims of restrictive institutional cultures and health system failures, could lead to improvements of those systems [6,9,15].
The Respectful Maternity Care (RMC) Charter, which was developed in 2011 by a group of international stakeholders, promotes the rights of women receiving maternity services [20]. Key principles of RMC are freedom from harm and mistreatment, privacy and confidentiality, the right to dignity, to information and effective communication [20,21]. Compassion, the increased attention to the suffering of others with intention to assist them [22], is an important component of RMC. Interventions achieving RMC are expected to empower midwives and women in childbirth, giving both more agency and control in making decisions for themselves.
For midwives this includes improved morale, greater professional pride and relatedness to each other. Building resilience, the ability of individuals to respond positively to adversity using effective coping strategies, is another component, based on midwives sharing social support and developing self-caring skills [23,24]. Education of midwives on the emotional and physiological aspects of labour, would expand their knowledge base to include understanding how scolding and shouting at women contributes to poor maternal and newborn outcomes [14,15,23]. However, education alone is insufficient to change attitudes and behavior and needs to be accompanied by a process of life-long learning that feeds into the construction of their professional identity as midwives.
Frenk et al (2010) have motivated principles of transformational learning (rather than informative or formative learning) as essential for strengthening health systems and improving quality of care [25]. The World Health Organization has also advocated more positive birth experiences [26]. Our interest was in how to put these concepts into practice. This qualitative study engages with the phenomenon of advancing RMC from the midwives’ perspective, to encourage sustainable behavior change, using methods grounded in promoting professionalism and rights of birthing women. The objective of the study was to assess changes in attitudes, behaviours and practices in a group of midwives in response to an educational intervention promoting RMC. Mezirow’s transformative learning theory [27–29] was used as a conceptual framework to explore the learning journey these midwives made in becoming “enlightened change agents” in relation to their work and for the birthing women they served. Critical self-reflection and challenge of core beliefs, assumptions and values, as a means of acquiring new knowledge by adult learners, are central elements of transformative learning theory. The ten phases of transformative learning [29] are listed in Table 1. Events of dilemma or dissonance are turned into opportunities for reflective inquiry, using for example dialogical learning within a group of midwives, to explore how they feel about incidents with women in their care [30,31]. Learners revisit their values and beliefs in relation to their new experience, questioning whether their worldview is accurate, to be changed or preserved. They discover new insights and self-awareness in relation to others. If learners change their views without questioning, or adopt new beliefs because of pressure on them, it will not be transformative [27].
We chose to use reflective writing journals as a source of data on the experiences and learning of the midwives in this study. Diaries and journals often provide better data for research than interviews or observations, especially where the information being gathered is sensitive or revealing. They are less limited by recall bias since entries are contemporaneous [32,33]. Reflective narrative writing by health professionals is a skill that increases self-confidence in applying knowledge and skills, allowing them to critically assess the impact of their behaviour, which when connected with bearing witness to events of tragedy and wonder, may modify their behaviour towards more patient-centred care [23,31,34,35]. Collaborative reflective practice through journal writing and dialogue between midwives could lead to more nurturing relatedness with each other and women in their care. Their sense of self-efficacy and professional identity would derive from belonging to a community of practice, which awakens their sense of resilience. Communities of practice are networks of individuals who, through their interactions together, develop a common sense of identity, sharing knowledge, exchanging ideas, insights, values, stories, practices and expertise [36,37]. Revisiting core beliefs and values through this process would take midwives back to their understanding of what being a caring professional means. Critical reflection skills, self-awareness and effective life-long experiential learning are necessary for remaining competent as health professionals who are able to self-monitor and self-regulate [35,38]
[ARTICLE CONTINUES, IT IS 30+ PAGES, IT IS EXCELLENT AND WELL WORTH READING IN FULL AS A SUCCESSFUL EXAMPLE OF HOW TO SUPPORT MIDWIVES TO PROVIDE THE CARE AND SERVICES TO PREGNANT WOMEN THAT THEY NEED!!]
PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0002008 December 22, 2023.