The complex and dynamic system underpinning midwives' approaches to SPL

Background: Slow progress of labour (SPL) constitutes the main cause of primary caesarean section and transfers of women from midwife-led units (MLUs) or home, to hospitals. It is also associated with maternal, foetal... [ view full abstract ]

Background: Slow progress of labour (SPL) constitutes the main cause of primary caesarean section and transfers of women from midwife-led units (MLUs) or home, to hospitals. It is also associated with maternal, foetal morbidity and negative birthing experience. The cascade of medical interventions characterising the current management ofto SPL has been increasingly questioned; nevertheless, alternatives are not widely reported. This study contributed by exploring midwives’ approaches to SPL in MLUs. Methods: Qualitative multiple case study, underpinned by a critical realist approach. Midwives’ approaches were investigated in an Italian alongside and an English freestanding MLU. Data collection involved documentary review, 24 individual semi-structured interviews, 2 focus groups, 415 hours of observations with midwives, managers and doctors. A within-case and cross-case thematic analysis led to original assertions and conceptualisation of the case. Results: Midwives perceived the issue of SPL differently in different sites. SPL was mostly acknowledged as a consequence of intertwined factors, with higher complexity where non-mechanical causes were involved. Observing women’s behaviour was suggested as pivotal in attempting to distinguish whether SPL represented a ‘rest or arrest’ phase of labour. Midwives used their senses and intuition in the process of recognition yet partogram and vaginal examinations were considered ultimate means of diagnosis. Midwives endeavoured to provide personalised care. Some interventions were universally adopted across cases but others were highly dependant on individual and contextual factors. Support, personal and organisational characteristics, and relationships occurring in and with the environment were key influential factors for decision-making. Discussion: Midwives’ understanding, recognition, decision-making process and management of SPL highlighted multifaceted aspects regarding SPL. In daily midwifery practice, coexistence of conflicting paradigms emerged. They included views on SPL as reality or construct, use of intuition or rationality, medical or midwifery culture.   Conclusion:  This is the first case study exploring midwives’ approaches to SPL in different MLUs and countries. Findings illuminate a complex and dynamic system where the variable interactions of similar influential factors result in variable midwives’ approaches. The study was self-funded and obtained all the necessary ethical approvals. Findings will be orally presented.