A phenomenological exploration of midwives accounts of midwifery expertise

Aim: This thesis reports the findings of a qualitative study which aims to explore the nature of intrapartum midwifery expertise using a phenomenological approach, in order to illuminate the essential characteristics and skills that facilitate optimal birth outcomes for women. The primary aim of the research was to gain an in-depth understanding of the meanings midwives place on the; 'nature of midwifery', 'normal birth', and 'expertise in childbirth', exploring these meanings in a cultural context. Background: Expertise in the context of nursing and medicine has been subject to much exploration and debate. However, there are very few studies of practitioner's accounts of expertise in the context of midwifery intrapartum care. Despite this, it is not uncommon for midwives to pronounce themselves the experts in, or guardians of normal childbirth. However, the statement appears to rule out expertise in situations where childbirth is not normal. As the majority of women giving birth in the UK currently do not experience a physiological birth, and indeed in many countries across the world, this raises questions both about the claim to expertise in normality, and its apparent demise, and about the provenance of midwifery expertise in general. Methods: A systematic review was undertaken in which twelve databases and fifty relevant journals were searched for papers published between January 1970 and June 2006. A subsequent qualitative study took an interpretative phenomenological approach. Group interviews (n4) and in-depth individual interviews (n=3) were used to capture data about the lived experiences of midwifery, normal childbirth, and expert intrapartum care. Findings: Data from the qualitative study identified fourteen codes (knowledge, experience, education, personal attributes, confidence, competence, judgement and decision making, technical and fundamental skills, belief and trust in birth, courage, intuition, midwife-woman relationship, midwife colleague relationship, and creating an environment of trust) which were combined to form four themes; 'wisdom', 'skilled practice', 'enacted vocation', and 'connected companionship'. Findings of this study suggest that there are three domains of expert midwifery practice;'physiological expertise', 'technical expertise' and 'integrated expertise'. Integrated expertise appears to be the strongest of the three, being characterised by the expert's ability to work across boundaries of normality and through differing models of care in order to promote optimal birth outcomes for women. Conclusion: Experts appear to negotiate the dichotomy between the medical and holistic model of care, subtly integrating the art and science of midwifery. As experts appear to overcome many of the cultural problems evident in practice, they may be regarded as valuable role models. These attributes may be used to challenge practice, in order to accommodate or overcome dissonance between different models of practice. This would in turn benefit the profession in terms of recruitment, retention and professional status. Data from this study add new insight to the nature of expertise. Data relating to midwives' attitudes, and the relationships that experts build with colleagues, appear to be significant new findings, and important concepts in the development of expert practice. However, further research would be required to identify and explore the domains of expertise proposed in this study