in a reduced risk of caesarean section, instrumental delivery and need for analgesia (McDonald 2011).
Innovations such as birthing pools, improved equipment and alternative therapies for pain relief used in labour have changed midwifery practices to ameliorate the birthing environment. However, organisational factors such as rising costs, shortage of staff and resources have had an impact on the provision and quality of maternity services. Over time, these have collectively had a significant bearing on women's satisfaction with their childbirth experiences and have ‘cost’ midwives and healthcare professionals in terms of their health and wellbeing (Leinweber and Rowe 2010; Amir and Reid 2018).
The new standards for the midwifery profession (NMC 2019, p. 16) state that a midwife must ‘Provide safe and effective midwifery care: promoting and providing continuity of care and carer’. It is unclear how midwives will be able to fulfil the expectation of continuity of carer when the midwifery workforce is depleted to a risk level that needs addressing urgently. Consequently, midwives are suffering from occupational burnout, experiencing stress and anxiety and need organisational and peer/colleague support (Yoshida and Sandall 2013). The Department of Health has recognised these shortfalls and currently changes are in progress. There is a move to improve and balance life/work conditions (Knapp 2017a) and change to bursaries for students entering the profession as a way forward for those who struggle, at personal cost, to provide safe and effective midwifery care.
Conclusion
This chapter has examined the literature that cites the ‘with woman’ concept and presented the findings through Rodgers' Concept Analysis framework. Further searches were carried out at the start of each subsequent chapter to add terms and associated concepts or surrogate terms specific to the chapter title; for example, the With Woman in Prison Chapter 9 (Shlafer et al. 2014) included word searches such as ‘with woman’ AND/OR pregnant, imprisoned, incarcerated, pregnant in prison, childbearing women in prison and maternity services in prison.
Stories from midwives and women complete the final stage of Rodgers' Concept Analysis framework to illustrate the findings from the analysis. Identified attributes of a positive calming presence, reassurance and nurturance through a therapeutic relationship resulted in empowerment and control for the woman and her partner and a positive birth experience.
Midwives' Story
Victoria's Story
Lisa*’s birth story: As a midwife I try to maintain a relaxing and calm atmosphere for the woman and her partner as it promotes a positive birth experience.
Lisa and David came into the midwife‐led birth centre for a labour assessment. Lisa was 40 weeks and four days pregnant with her second baby. All of her observations were within normal limits and she was contracting three times in 10 minutes, which felt moderate on palpation. Her waters were intact and the fetal heartrate was normal when I listened in. I took her into a room and encouraged her to eat, drink and mobilise. At this point, her contractions were regular, and I did not feel that there was any indication to offer a vaginal examination.
Whilst they waited for labour to progress, David put some music on a speaker and I turned the lights down low. Lisa breathed calmly through her contractions for a couple of hours whilst I quietly observed her and listened to the fetal heart (FH) every 15 minutes. I also offered aromatherapy, which was accepted. Lisa inhaled frankincense and black pepper oils from a cloth whilst her contractions increased in strength and frequency.
As she began to feel pressure, her waters broke, and she requested to use the birthing pool. She visibly relaxed as she entered the warm water and began to bear down in an all fours position. Aside from quietly listening in every five minutes and checking Lisa's pulse, the room was quiet. David moved a chair closer to the pool and held his wife as she began to have expulsive contractions.
The atmosphere in the room remained calm and primal as the vertex became visible. Lisa listened as I calmly guided her to stop pushing as baby's head crowned. She reached down to touch her baby's head before the body was born with the next contraction. I passed her pink and crying baby girl up to her chest. Lisa held her baby for 10 minutes until the cord stopped pulsating and as baby was keenly searching for her breast. David cut the baby's cord and had some skin to skin with his new daughter whilst I helped his wife out of the pool. The placenta was delivered passively on the toilet into a bowl and, as Lisa had an intact perineum, she began breastfeeding within 30 minutes of birth. As a midwife I helped to facilitate this birth for this couple; however, the woman and her partner were fully in control of the environment and their own experience.
Lucy's Story
Fiona*’s birth story: To me, midwifery‐led care is about being with woman – not just in the physical sense, but holistically engaging with her, understanding her story and actively listening. I feel extremely privileged, within the National Health Service (NHS), to work in a home birth team, case‐loading and providing community to our clients. Through this level of continuity, I feel I have been able to give the best care of my career, because for the first time I am getting to know the women we care for. As a team we care for mothers throughout their pregnancy, and spend time understanding them as an individual. What motivates her? What are her fears? What are her preferences and why? What does she find supportive and obstructive? Listen carefully to a mother and she will tell you her story; engage with her and you will understand it.
One evening I was first on call, about five months into my career with the team, and about 18 months post qualification. I received a phone call from Fiona, a term mother, at about 9 p.m. to say her waters had broken. This mother was someone I had booked under the team's care when she transferred to us in the third trimester from another location. She had a previous home birth elsewhere and was incredibly calm as a person. Her first birth had been straightforward and had been the quicker side of ‘normal’. I confirmed her waters were clear, and baby was moving well. Fiona reported feeling very comfortable, with just a few ‘niggles’ so far. Guided by this information and her relaxed manner on the phone, I suggested she rest and call back when things changed or if she had any concerns.
A few hours passed, and I received another phone call. Still calm and relaxed, Fiona told me that she was now having two contractions every 10 minutes. She felt they were mild to moderate in strength but could feel they were beginning to spread from previously being low and crampy to now up and across her abdomen. They were lasting about 40 seconds. By textbook definition, I knew that this indicated that Fiona was not in ‘active’ labour, as her contractions were not yet regular or occurring 3 : 10 lasting 60 seconds. But on hearing her pause and breathe through a contraction on the phone, I felt that I should make my way to her.
When I arrived, Fiona was quietly pacing in her room using a TENS machine and listening to a relaxation track. I checked my kit and quietly set up my resuscitation equipment – the family had a full discussion with us at a 36 weeks antenatal appointment and knew what kit would be present. So this was not alarming. I completed a full assessment – observations, abdominal palpation, began regular auscultations and then sat back and observed her. Liquor remained clear, and baby was still moving well; all was well. We do not routinely perform vaginal examinations, unless requested or unless there are any deviations from normal, for at least the first four hours – within which time many mothers have birthed or are close to birthing.
Fiona continued to pace, and I observed as she paused to breathe through each contraction. I noticed she was now contracting about three times in every 10 minutes, but reflected on how on an average triage shift, a mother as stoic as her would likely have midwives saying ‘she's
