Women and Birth 33 (2020) e455–e463

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Women and Birth

journal homepage: www.elsevier.com/locate/wombi

A qualitative study of factors that influence midwives’ practice in

relation to low-risk women’s oral intake in labour in Australia
Mika Tadaumia , Linda Sweeta,b,* , Kristen Grahama
a
College of Nursing and Health Science, Flinders University, Australia
b
Deakin University and Western Health Partnership, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: Restriction of food and fluids during labour increases women’s discomfort, anxiety and
Received 28 November 2018 stress which are associated with obstruction of the normal process of labour. Whilst research evidence
Received in revised form 14 November 2019 and clinical guidelines recommend that normal uncomplicated labouring women should not be limited
Accepted 14 November 2019
in their oral intake during labour, some midwives continue to restrict or discourage women’s oral intake.
To promote best practice, it is important to understand the influencing factors which affect midwives’
Keywords: decision-making processes.
Decision making
Objective: This study aimed to investigate the influences that affect midwifery practice regarding oral
Labour care
Nutrition
food and fluid intake for low-risk labouring women.
Midwifery Design: An interpretive descriptive approach employed 12 semi-structured interviews with registered
Oral intake midwives with current labour and birthing experience in Australia. Data was analysed using thematic
analysis.
Findings: Three themes were identified: midwives’ knowledge and beliefs; work environment and
women’s expectations of care. Midwives’ practice was affected by their knowledge and values developed
from professional and personal experiences of labour, their context of practice and work environment,
the clinical guidelines, policies and obstetric control, and women’s choice and comfort.
Conclusion: This study indicates that midwives’ decision-making in relation to women’s oral nutrition
during labour is multifaceted and influenced by complicated environments, models of care, and power
relations between doctors and midwives, more so than clinical guidelines. It is important for midwives to
be aware of factors negatively influencing their decision-making processes to enable autonomy and
empowerment in the provision of evidence-based care of labouring women.
© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

What is already known

Statement of significance
Problem of issue
Restriction of oral intake during labour leads to an increase in
women’s anxiety, stress and discomfort which may obstruct
the normal progress of labour.
* Corresponding author at: School of Nursing and Midwifery, Deakin University
and Western Health Partnership, 221 Burwood Highway, Burwood, Vic, 3125,
Australia.
E-mail address: l.sweet@deakin.edu.au (L. Sweet).
Women’s oral fluid and food intake in labour does not
negatively affect any significant maternal and neonatal birth
outcomes. Midwives providing labour care are able to
provide or restrict food and fluids for women in labour.
What this paper adds
Midwives’ knowledge and beliefs, workplace environments,
and women’s’ expectations are factors which affect mid-
wives’ decision-making in relation to women’s food and fluid
consumption during labour. Participants’ practice was most
influenced by the institutional and hierarchical cultures
where they worked which influenced their capacity for
autonomous decision-making. This paper provides insight
into the factors which influence midwives decisions regard-
ing oral intake in labour, with the aim of increasing their
awareness, autonomy and empowerment in the provision of
evidence-based care of labouring women.

http://dx.doi.org/10.1016/j.wombi.2019.11.004
1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

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e456 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
1. Introduction
Midwives’ decision-making is a crucial part of the assessment
and support of labouring women [1]. Oral food and fluid intake
during labour is needed for women’s physical energy require-
ments, and for their stability, contentment, and control in labour
[2]. A lack of energy and hydration leads to ketosis which causes
exhaustion and may prolong labour [3]. In 1946, Dr Curtis Lester
Mendelson found that some women who consumed food and fluid
during labour suffered pulmonary aspiration while having a
caesarean section under general anaesthesia, increasing the risk of
maternal death; a condition known as Mendelson’s Syndrome [4].
Because of this, the restriction of women’s oral intake during
labour became routine practice around the world [4]. Recent
research has shown that women’s oral fluid and food intake in
labour does not negatively affect any significant maternal and
neonatal birth outcomes [5]. Furthermore, there were no reports of
maternal mortality caused by Mendelson’s Syndrome in Australia
from 2006 to 2010 [6]. Currently, the World Health Organization
recommend labouring women be encouraged to consume nutri-
tious food and fluids during labour as desired [7]. Following clinical
experiences in Japan and Australia it became evident to the
primary researcher that midwifery practices regarding women’s
oral nutrition during labour in Australia does not always meet
these guidelines, and therefore warranted further exploration.
Research into midwives’ decision-making specific to women’s oral
intake during labour is limited [8]. There are limited studies which
relate specifically to the provision of oral food and fluid intake in
labour, with only one out-dated study [9] exploring the relation-
ship between midwives’ decision-making and women’s oral intake
during labour. As a result, further research on this topic is
warranted.
This study aimed to investigate the influences that affect
midwifery practice regarding oral food and fluid intake for low-risk
labouring women. The research question was “What factors
influence midwives’ practice regarding low risk women’s oral
intake during labour?” Women’s oral intake during labour was
defined as women who eat food and drink water, ice chips, isotonic
sports drink, fruit juice, tea and/or coffee during first and second
stages of labour [2]. The term ‘low-risk uncomplicated labouring
women’ was defined as women within 37–42 weeks of pregnancy
who do not have any disease or illness (including hypertension,
pre-eclampsia, eclampsia, diabetes, a previous abdominal surgery,
neurological disorders, oesophageal diseases, placenta previa, or
fetal complexity), and with a normal progress of labour [10].
2. Background
Research into midwives’ decision-making specific to women’s
oral intake during labour is limited [8]. Literature does however
identify influences of midwives’ general decision making in the
provision of labour care. Midwives report feeling that hospital
guidelines, policies, and models of care limit their options relating
to their provision of midwifery care for women [9,11–15]. In
addition, place of work, the work environment, and workload
pressures have all been identified as contributing factors in
decision-making and clinical practice [11–14]. Further, midwives
reported that when obstetricians or senior midwifery colleagues
offered direction for women in labour, they felt obligated to
comply [11,13,14,16].
In relation to midwives autonomy to practice, the notion of
professional persona, including midwives’ experience, knowledge,
and confidence has been shown to have a significant influence on
their decision-making during labour care [9,11,13,17]. Midwives’
previous professional practice, values and beliefs were notable
further contributing factors. For some midwives, their professional
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persona included the notion of highly specialised skills in the care
of labouring women, oftentimes accompanied by greater under-
standing of women’s needs than other professionals in the area.
Finally, the labour and birthing expectations of women,
including their requests, desires and practices influenced mid-
wives’ decision-making and rapport building capabilities
[11,15,17]. Cultural factors which impacted the beliefs, behaviours,
and desires of the labouring woman, including physical signs and
emotional aspects also guided the way in which midwives
provided care [12].
These studies provide a general understanding of the main
elements that influence midwifery practice in labour care.
However, there are only limited studies which are related
specifically to the provision of oral food and fluid intake in labour,
with only one out-dated study [9] exploring the relationship
between midwives’ decision-making and women’s oral intake
during labour. As a result, further research on this topic is
warranted.
3. Methodology
An interpretive descriptive approach was chosen as the best
methodology to answer the research question as it can be used for
understanding the holistic real-world [18,19]. Interpretive descrip-
tion is an inductive analytical approach designed to understand a
phenomenon for the purpose of capturing subjective experiences
and generating interpretations which have the ability to inform
practice [19]. This approach can assist with the development of
appropriate knowledge for the clinical context of health practice,
which is fundamental to comprehending how targeted groups
behave and what comprises the central nature of the human
experience. Moreover, it seeks to maintain a practical application,
whilst acknowledging the various conceptual frameworks of
different disciplines [18,19]. To explore the experiences of mid-
wives decision making around women’s oral intake during labour,
it was important to understand midwives’ perceptions of how
knowledge, behaviours, attitudes, and opinions influence practice
[18,19]. As midwifery practice regarding women’s oral intake
during labour is associated with the subjective nature of decision-
making and the many factors that may influence it, an interpretive
descriptive approach was most appropriate.
3.1. Ethics
Human research ethics approval was gained by the Flinders
University Social and Behavioural Research Ethics Committee
(no.7400), and informed voluntary consent obtained from all
participants. Confidentiality was maintained through the de-
identification of names of people and places.
3.2. Participant sampling
Purposive and snowball sampling were used to recruit
participants. Purposive sampling is used to recruit participants
who have specific experiences, knowledge, and skills [18], while
snowball sampling enables participants to invite colleagues who
met the inclusion criteria to participate [18]. We sought English-
speaking registered midwives, who currently provide labour and
birthing care across a range of clinical practice settings in Australia.
Midwifery students who do not have final decision-making
capacity for women’s care were excluded. For qualitative research,
the collection of rich in-depth data is more important than the
number of participants [18]. Research has shown that six to twelve
interviews are sufficient to achieve most qualitative studies’
research aims and objectives [20]. With this in mind, we aimed to
recruit a minimum of 10 participants across a range of practice
 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463 e457

settings, with the capacity to seek more if data saturation was not
achieved. We felt it important to also achieve variation in practice
contexts including public and private settings, across rural and
metropolitan locations to gain insight into the different contexts of
midwifery practice.
3.3. Participant recruitment
An invitation, information sheet and consent form were
emailed to all registered midwives on a single university’s email
contact list, inviting them to participate in the study or to forward
the request to colleagues who may meet the inclusion criteria.
Individuals willing to participate contacted the primary researcher
to confirm their interest and arrange an interview.
4. Data collection
Semi-structured interviews were used, enabling the partic-
ipants to speak about their experiences through the interviewer’s
guiding questions [18]. The interview questions were developed by
the researchers and trialled with one midwife, after which minor
refinements to the order and content of questions were made.
Interviews were conducted face-to-face, or by phone or Skype and
lasted from 30 to 50 min. Whilst the audio/visual medium differed
due to geography, all interviews used the same question set and
were conducted by the same researcher. All interviews were audio
recorded and then transcribed verbatim by the principal research-
er. All data was de-identified to maintain confidentiality and
anonymity [18].
4.1. Data analysis
An inductive thematic analysis following Braun and Clark’s six-
step process was used [21]. This approach seeks to develop
common meanings based on peoples’ experiences regarding a
particular topic [21]. Firstly, the audio-recorded interviews were
listened to while reading the transcripts many times to understand
the participants’ words in order to find the inherent meanings [21].
Secondly, the data was coded with the use of NVivo 11 [21]. The
third step was to identify the emerging themes [21]. Step four
involved revising the themes based on the coded data and the
entirety of the data, to check quality [21]. Specifying and naming
themes was undertaken as step five [21]. The final step, step six,
was creating a report to describe a compelling story about the data
analysis which can answer the research question [21]. Initial
coding of all transcripts was undertaken by the principal
researcher, whilst the co-researchers independently coded three
interviews each to enable cross-referencing and analytical
discussions. The co-researchers also examined the emerging
NVivo file for depth and completeness of coding. Categorisation
and thematising were collective events through iterative dis-
cussions and negotiation. Therefore, all of the research team
contributed to the analysis by coding the data, checking coding and
naming themes. At the conclusion of analysing twelve interviews it
was deemed that data saturation had been achieved and
recruitment ceased.
4.2. Trustworthiness
‘Trustworthiness’ refers to the quality of qualitative research.
Trustworthiness in this study is demonstrated by participant
variation, the consistent data collection approach, verbatim
transcription of data, and careful analysis. Checking of each
transcript against the audio recording enabled the principal
researcher to be immersed in the data. Reflexivity was achieved
through the collective and iterative analysis of the data and
checking of categories and themes with all team members. All of
the study processes were reviewed and overseen by the experi-
enced supervisors to ensure confirmability. Furthermore, sufficient
detail is described to establish research which is transferable.
5. Findings
Twelve midwives participated in this study. The participants
varied in age, workplace type and location, type of midwifery
education, years of experience, and registered nurse qualification
(see Table 1).
The participants identified a variety of factors which affect their
decision-making in relation to women’s food and fluid consump-
tion during labour. Despite the diversity of characteristics of
participants, the thematic analysis of the data resulted in three
themes which were evident across all participants. These were:
“Midwives’ knowledge and beliefs”, “Work environment”, and
“Women’s expectations of care”. These three themes are inter-
related and help us to understand the complexities of midwives’
decision-making and practices regarding women’s oral intake
during labour.
5.1. Theme 1. Midwives’ knowledge and beliefs
All the participants identified that knowledge gained from
their pre-registration education, continuing professional devel-
opment, and personal and professional clinical experiences
influenced their beliefs and practice. The data revealed an

Table 1
Participants’ demographic information.

Participant Data collection method RN Years Model of care Location Context Type of qualification Age
No. as RM
1 Phone Yes 6 Secondary Hospital Rural Public Bachelor of Midwifery & Master 39
of Midwifery
2 Face to face at a cafe Yes 26 Midwifery Group Practice Metropolitan Public Hospital certificate course 54
3 Face to face at the University No 10 Tertiary hospital Metropolitan Public Bachelor of Midwifery 54
4 Face to face at the University No 2 Midwifery Group Practice Metropolitan Public Bachelor of Midwifery 24
5 Skype No 3 Secondary Hospital Metropolitan Private Bachelor of Midwifery & Master 41
of Midwifery
6 Skype Yes 31 Secondary Hospital Rural Public Hospital certificate course 54
7 Phone Yes 21 Tertiary hospital Metropolitan Public Bachelor of Midwifery & Master 47
of Midwifery
8 Face to face at the University No 4 Secondary Hospital Rural Public Bachelor of Midwifery 33
9 Phone No 10 Secondary Hospital Rural Public Bachelor of Midwifery 48
10 Face to face at the hospital No 51/2 Tertiary hospital Metropolitan Public Bachelor of Midwifery 34
11 Phone Yes 4 Secondary Hospital Metropolitan Private Bachelor of Midwifery 48
12 Phone Yes 161/2 Secondary Hospital Metropolitan Private Bachelor of Midwifery 42

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e458 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
apparent tension in s midwives’ decision making processes
between their knowledge of evidence based best practice and a
desire to support women’s oral intake, and the concerns for safety
and minimising the potential risk of complications. Three sub
themes help to explain this.
5.1.1. Education
The participants’ theoretical and clinical educational experi-
ences, which promoted women’s oral intake during labour to
maintain their hydration and energy and therefore improving their
comfort, impacted upon their decision-making in midwifery
practice. Regardless of the type of midwifery education or duration
since their education (see Table 1), all participants recalled
learning about oral intake in labour including Mendelson’s
syndrome in their pre-registration education. Participants’ pre-
registration midwifery education and their graduate year experi-
ences were found to influence their decision-making regarding
women’s oral nutrition in labour. In response to specific ques-
tioning relating to education around oral intake during labour,
participants described learning the importance of supporting
women’s oral intake during labour as they wish. However, they
also learned that there exists a—albeit minimal—risk of pulmonary
aspiration under general anaesthetic which generated tension
around whether they should ‘allow’ women to eat or drink during
labour. Participant 11 said “Then you have got the risk of, you know
vomiting and aspiration. I think that’s a very big risk”. Six of the
participants recalled previously discussing women’s oral intake
during labour with other midwives while on clinical placement as
a midwifery student or as a graduate. One participant had worked
with many midwives and doctors with differing views, which has
enabled her to come to her own decisions about women’s oral
nutrition for women in labour.
.. then there is doing placement. You learn how midwives work.
All midwives are different, but you learn from them and you
find the best option that sits with you ethically. And then you
work on the situation with the woman and how they are
progressing through labour, and then provide them all the
information. So, it’s just learning on the job. You know, taking
bits from different midwives and doctors and putting that into
practice to best benefit the woman. (P.5)
Another participant explained that her knowledge regarding
nutrition in labour was gleaned from university and through peers
and experience:
I think it’s probably most at Uni. It was not a topic that I have
gone in and researched myself . . . I have just gone by what I
learned in Uni and what I have been told. Picking up
[knowledge] just working (P.4)
Six participants had experience working as a university lecturer,
clinical facilitator or preceptor, and therefore had reviewed recent
literature and midwifery guidelines regarding women’s oral intake
during labour, to provide current evidence-based practice educa-
tion to midwifery and medical students. However, they acknowl-
edged that the information they taught to students about women’s
oral intake during labour was not always the same as what they
practiced. They taught women’s oral nutrition in labour should not
be restricted as it is the midwives’ role to promote physiological
labour and birth and to empower women. However, these
participants spoke of the influences of institutional culture and
guidelines rather than education, which limited their capacity to
support women’s oral intake during labour. Participant 3 said “I
wish that my place of work was more responsible, and more evidence
based around feeding women in labour. I don’t believe they are really”.
Participants described how many practices were sometimes in
conflict with the latest evidence, and that their knowledge and
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experiences in an educational role were not valued in the decision-
making process.
The three participants who were also registered as nurses,
reported that their nursing background influenced their decision-
making and labour care, as they were concerned with the possible
complications resulting from women eating and drinking during
labour. Interestingly, they spoke of not limiting women’s oral
intake during labour; nevertheless, they did not encourage
women’s food and fluid consumption in labour either. Their
nursing education and experiences appeared to increase their
consideration of the potential pathology in their midwifery care
decision-making.
I actually think since I have done my nursing, I have become
more cautious when it comes to those sorts of things . . . [In
midwifery] There is lots of focus on natural and normal. You are
not really thinking about the pathological science of things,
dehydration, things like that as much as you are when you have
a nursing background. I do, sometimes I am thinking about the
nursing point of view as much as the midwifery point of view
(P.11).
Previous nursing education and experience therefore appears to
influence midwives’ perceptions of risk for women eating and
drinking during labour and therefore their decision-making.
5.1.2. Safe practice
Most participants indicated that their understanding of risk
influenced their decision-making. Risk management was a
significant consideration regarding women’s oral intake during
labour. Some participants reported that they were concerned that
allowing women to freely eat and drink during labour was a risk,
because they cannot predict labour progression and birth
outcome.
Especially when you’ve got primips most in mind . . . if they go
to section, you’ve got that potential for aspiration, especially if
they have a first section, you need to do GA [general
anaesthetic]. I think that’s very important to ensure that you
definitely know when is the last time they have eaten. And if
you’re doing an induction, we always err on the side of caution
in regard to food. Because you just don’t know what is going to
happen (P.11)
Women’s stage of labour influenced midwives’ decision-
making. Half of the participants commented that they encouraged
women to eat and drink in the latent/early and active stages of
labour. The remaining participants did not encourage women to
eat during the active stage of labour due to the potential risk of
instrumental birth and caesarean section.
I encourage [food and fluid for] the normal women in labour, I
do not tend to restrict them in what they can eat, early on and
then even when they’re in the active stage . . . Over the years, I
have watched them, and I tend to find they don’t tend to go to
anything heavy. So it is not like I’m discouraging it . . . They
will always ask me, they’ll say, “Am I allowed to eat?” I guess
that’s when I do say “Anything small, so crackers and lollies,
anything like that,” and they say, “Yeah,” and they quite often
say, “Yes that is, you know, that is all I feel like.” So that makes
me feel good knowing that, that’s all they feel like. I am not
restricting them too much, so that is good. So, I am quite happy
(P.12)
All the participants indicated that they encouraged fluids rather
than food, to maintain hydration and minimise the risk of a full
stomach. The participants were aware that dehydration could
result in maternal exhaustion and fever, prolonged labour, and fetal
tachycardia, and a full stomach was thought to increase the risk of
nausea and vomiting, as well as aspiration.
 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
If I have a lady who is looking like she is going to get an epidural,
she is probably not progressing well you know. She has the
Synto [Syntocinon] going, and we are in the last phase of ‘are we
going to birth vaginally or not?’ Then, at this point, I would
probably discourage eating and drinking, and having enough
drink (usually we have got fluid going), just enough to keep
comfortable, like their mouth moist and sips rather than filling
up their belly at that late stage when they are looking like they
might be off to theatre. (P.1)
With uncertainty about risk status, participants often took a
conservative approach to supporting fluids over food.
I know the risk about aspirating. The risk of having general
anaesthetic, aspirating is tiny. But it’s like anything we do, it is
risk management, is it not? (P.8)
The participants showed that decision-making in relation to
women’s fluid and food consumption is affected by their
professional responsibility to provide safe practice, including
reducing the risk of dehydration and pulmonary aspiration.
5.1.3. Clinical and personal experiences
The participants’ clinical and personal experiences are factors
that influence their decision-making in relation to women’s food
and fluid consumption during labour. All the participants indicated
that they had not provided care for a woman who had suffered
from Mendelson’s Syndrome. Despite this lack of direct experience,
they all understood that it was a risk. One participant explained the
risk related specifically to general anaesthetics and the experience
of her medical colleagues.
If they do have to go to theatre and if they have to have a GA, um,
a general anaesthetic, obviously that risk is, is quite large and I
have spoken to anaesthetists that have seen it. Women, that
have ended up in intensive care with gastric aspiration, they
were very sick. So there is a reasoning behind it, obviously
there’s evidence to say you know. (P.12)
Many of the participants shared stories however of women
eating and drinking during labour without negative effects.
We had a multi who broke her waters in the morning. She had
contractions for a couple of hours and they stopped. In the
meantime, because no-one had gone to see her, her lunch was
delivered to her room, she ate her lunch, and had a baby one
hour later. I always remember this story forever and ever. (P.9)
The participants’ perception of the minimal risk of Mendelson’s
Syndrome, as opposed to their positive experiences of women’s
eating and drinking during labour, influenced their decision-
making to allow, or encourage, oral intake, particularly for women
without complications and for women in early labour. Further-
more, they spoke of the use of medications and anaesthetic
techniques which minimise the risk of pulmonary aspiration and
the small percentage of women requiring a general anaesthetic.
Participant 6 explained “And because we give sodium citrate and
ranitidine, stuff like that. You know, that seems to have helped with
any problems”. Similarly, participant 2 explained “Only 1 to 2% have
general anaesthetic. A huge number of them are women who have
epidurals”.
Some participants indicated that their own negative birth
experience regarding the restriction of oral intake during labour
influenced their midwifery practice. These participants spoke of
detrimental effects of being denied oral intake during labour. One
example of this is expressed below.
My main influence is my own experience of not being allowed
to eat in labour. I ate a chip and a midwife yelled at me. Because
my husband was eating chips. and I ate one, then she said,
‘You’re not allowed to eat that!’ And she worried about it,
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e459
because I ate a chip. I had such a terrible midwifery experience
(P.8)
A number of participants described encouraging oral intake for
women in their care because of their own similar previous
experiences. Their stories described a lack of empowerment during
their own labour, which impacted on their current practice as they
strived to promote positive birth experiences for women in their
care.
5.2. Theme 2. Work environment
The second theme, ‘work environment’, has four sub themes
and demonstrates how participants identified how their ‘location’
of practice, the healthcare ‘system’, their midwifery and obstetric
‘colleagues’, and ‘clinical guidelines/policies’ influence their
decisions and practices in relation to labouring women’s oral
nutrition.
5.2.1. Location
The participants’ place of work included metropolitan and rural
hospitals which influenced the size of the birthing unit, the
number of births they experienced, the acuity of the women they
cared for, as well as the number and mix of staff. Such locations
were shown to influence decisions regarding women’s oral intake
during labour.
I guess you are going to a look at demographic at [name of the
hospital]. We have a very, very high number of what we
consider high-risk women. We take the highest risk women in
the state. The caesarean rate is enormous. So, all of those factors
affect my own decisions (P.3).
Participants who worked in small rural hospitals explained that
there were only one or two midwives allocated per shift, caring for
low-risk women which gave them more autonomy to make
decisions and to promote woman-centred care.
We were able to, you know, I guess be independent in our roles
as midwives to decide or not to decide. Like um how you should
manage women with food and drinking in labour, rather than
having some sort of guidelines or policy doctors say . . . So, I
think it is good that people trust your judgement toward what
they eat and drink in labour (P.6)
Furthermore, participants who worked in midwifery group
practice (MGP), a midwife led continuity of care model, and in
metropolitan private hospitals were not influenced in their
decision-making by the location of the hospitals.
Culturally, I think that the culture of MGP is quite different to
the rest of hospitals. So, we would be encouraging women to
eat. I think I would be consistent what Group Practice do. They
are encouraging people to eat and drink and certainly not
restricting their foods. (P.2)
The MGP and private hospitals have a different context of
maternity care; that is, a midwife-led care model and the obstetric-
led model of care, respectively. Because of this, these participants’
practice regarding women’s oral nutrition in labour were affected
more by the model of care and ‘systems’ than the hospital location,
which will now be explored.
5.2.2. Systems
The participants worked in different health systems and models
of maternity care which greatly influences their practice. Models of
care determine the lead care provider for a woman’s maternity
care, with midwives’ role in the public and private systems and
models of care differed. All participants working in private
hospitals were located in the metropolitan area, and while looking
e460 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
after women in labour kept in contact with the obstetrician to
ensure that the obstetricians’ instructions were implemented.
It is really important keeping in contact with them [obstetri-
cian], in communication with them to say ‘This is what is
happening, are you happy with this happening?’ I cannot see
them changing their practice. It’s just a standard thing for them
to say (P.12)
Similarly,
We all pretty much practice the same way. We are all bound by
the individual likes and dislikes of the obstetricians who work
there. Essentially, obstetricians bring women to the hospital, so
we do have to give them a lot of respect, but we will always
advocate for what women want (P.11)
In comparison, in the public sector standard model of care,
midwives look after labouring women in consultation with the
duty obstetric registrar. This leads to a more guideline driven
decision process.
I do not feel great about that . . . I wish I could practice more,
. . . our challenge is being a midwife in such a big public
hospital . . . I am operating about 25% of what I would like to
be doing and 75% of what the hospital [require me to do] (P.10)
In the MGP model, whilst part of the public system and located
in tertiary hospitals, the midwives have more autonomy in their
practice.
I think that the culture of MGP is quite different to the rest of the
hospitals. We would be encouraging women to eat . . . and
drink, and certainly not restricting their food (P.2)
As such, MGP midwives mostly encourage food and fluid intake.
Whilst in the same institution, the care practices are different in
the regular birthing unit.
I am working in Midwifery Group Practice, it’s a lot more
focused on women’s choices, woman-centred care. . . . Outside
of Group Practice, they are a bit different . . . midwives in
delivery suit who are not in Group Practice would say ‘No, you
cannot eat.’ You know, full stop! (P.4)
The participants described how private obstetricians in private
hospitals, and obstetric registrars in public hospitals work within
obstetric models of care, and often dominate women’s care.
Participants working in an obstetric model of care identified a
hierarchal structure which impacted their decision making, in
comparison to midwives working within a midwife led care model
who identified a higher level of autonomy.
5.2.3. Colleagues
Most participants identified their medical and midwifery
colleagues as influences on their support of women in labour in
relation to their oral nutrition. The five participants who worked in
a tertiary public hospital, including MGP, indicated that they had
experienced being instructed to limit oral intake for women during
labour by obstetric registrars and senior midwives.
I think there is conflict. Yeah, because it also depends on the
registrar or doctors who are there. You know, it depends on
what they want. And then you sort of negotiate with them or
explain to the women. Because the doctors just come in and go
‘Oh I don’t allow you to eat and drink.’ And don’t explain that.
Then, you’re explaining that. And then they might be really
hungry now (P.5)
Whilst a number of participants identified the need to practice
in accordance to evidence, the data demonstrated that midwives’
practices still vary and with some participants identifying that
their own practice and instruction to more junior midwives may
not be e based on the latest evidence.
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. . . a lot of the senior midwives are more old-fashioned and
agree they should not be eating. But I think my generation, and
more recent graduates, might have the new thought [allowing
women to eat and drink during labour] (P.10)
Whilst less evident, in a rural hospital a hierarchy of decision
making is also evident.
Um, I think that is very well established; we do not have any
restriction in our workplace. But I feel underlying, um, pressure
from doctors, particularly if they look like they are going toward
caesarean, (P.9)
Nonetheless, three participants who work in rural hospitals
indicated that they had never experienced being directed to limit
women’s oral nutrition in labour by their medical colleagues.
Mutual respect and collaboration were considered important.
I think our GP is, um, because we do work as a team, I guess that is
shared. Because you know sharing the care. Even though they [the
doctor] are like the ultimate person who’s responsible, they do
not tend to have any stipulations about whether they should eat
or drink or not. And so, we are not sort of told by the doctors (P.1)
The culture and practice in hospitals is influenced by midwives’
knowledge, values and beliefs and when these differ, may lead to
conflict between colleagues. The participant midwives working in
tertiary public hospitals, except through the MGP model of care,
and private hospitals in urban areas felt conflict between obstetric
registrars’ and private obstetricians’ preferences and their own
knowledge and desire to meet women’s needs in relation to freely
allowing women to eat and drink during labour. The influence on
midwives’ decisions regarding oral intake in labour by medical
staff and senior midwives’ is largely related to their level of
experience, the model of care and their autonomy.
5.2.4. Clinical guidelines/policies
All participants indicated that local and state based clinical
guidelines/policies governed their practice to maintain safe and
high-quality midwifery care and influenced their decision making.
However, despite this, many participants were not knowledgeable
of the actual content of the government or hospital guidelines
regarding women’s oral intake during labour.
No, I do not know what they say [guidelines or policies]. I feel a
struggle with women who eat and drink. I start to feel
embarrassed that I haven’t perhaps kept up with what is the
policy, because it is an area where I tend to go with my own
practice here (P.2)
In a private hospital, the individual obstetricians’ instructions
or standing orders were considered the guidelines for care which
created a sense of conflict in the midwives’ provision of care.
In our hospital, I do not think there is a guideline. I think that
guidelines are unspoken words from the obstetricians. In
private institutions, the obstetricians tend to let us know what
they want and what they do not want. That can be difficult,
because you know the midwives want to practice from the PPGs
[Perinatal Practice Guidelines] and certainly a lot of our practice
comes from the PPGs . . . I guess you have to respect what they
[obstetricians] want, so it affects me in a sense (P.11)
Whilst not knowing the specific content of their clinical
guidelines, all participants knew where to find them should the
need arise, for instance, to justify their clinical decisions.
I guess, certainly if I were to be challenged or questioned about
what I was saying about nutrition and hydration during labour, I
would, that would be a first place I would go to have a look and see
what the guidelines say. I could back myself up and say ‘Well, a
guideline says this is what I am doing, so leave me alone. (P.7)
 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
Whilst guidelines exist, this study shows that it is the
institutional cultural practice that influences decision making
more than the guidelines themselves. The practices may be
consistent with the guidelines, however given the varied practices,
it is unlikely this is always the case.
5.3. Theme 3. Women’s expectations of care
All participants identified that women’s expectations of care
influenced their decision-making in relation to women’s oral
intake during labour, and that despite influencing factors that they
tried to empower women and respect their right to make decisions
regarding their labour experience. Furthermore, participants
stated that women should have a right to determine whether
they eat or drink during labour to maintain their comfort and sense
of being in control, however there was acknowledgment that this
did not always occur.
5.3.1. Women’s choices/desires
At times, a woman’s expectations and desires conflict with the
health service culture and staff expectations, and this resulted in
midwives needing to empower women to make informed
decisions, and advocating on their behalf
My main philosophy is working with giving women a choice
and helping them make an informed choice, making sure they
know that. . . . If they do not want, you know . . . they do not
want to follow the recommendation that is okay . . . I support
them. Women should have the choice to eat and drink. They
should be educated about . . . I guess the disadvantage, or the
potential risks might be very small (P.4)
The amount of antenatal education afforded to women was
thought to influence their empowerment to choose their care. As
the information women receive from health providers, health
education literature and online sources can be quite diverse
regarding women’s food and fluid consumption during labour,
women’s levels of knowledge may vary considerably, affecting
their agency in determining what they eat and drink during labour.
Furthermore, five participants stated that women’s cultural
backgrounds influenced their desires to drink or eat during labour
which, in turn, affected their midwifery decision-making. For
example, some women bring their own special soup and rice to
hospital, and eat these during labour, which is an important part of
their traditional practice for childbirth. The midwives did not feel it
appropriate to restrict these cultural practices in the context of
labour care.
I think it is an, it is an individual thing. Labour is so individual,
and cultural practices come into that. So we do have to be
respectful. This is one of the most important times of their life,
so I think we need to make them feel special (P.12)
The participants identified that women’s choices and desires
are significant factors in influencing midwifery care in relation to
the provision of oral nutrition during labour, as they attempt to
enhance women’s positive birth experiences. Nevertheless, those
who worked in private hospitals and in tertiary public hospital
models felt the strain between respecting women’s choices and
desires and obstetric and senior colleagues’ control when they
make decisions about nutrition during labour.
Sometimes it can be very difficult to explain to women that
unfortunately your obstetrician doesn’t want you to eat. They can
be difficult subjects. But, generally speaking, if we said to the
women not allow to have anything to eat, they may be upset. Then
the obstetrician says ‘No, you know you’re not allowed to have
something to eat during labour.’ They will just accept it. Because
they tend to respect that authority level more. (P.11)
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e461
5.3.2. Women’s comfort/sense of control
Most participants identified that women’s eating and drinking
during labour may be needed to maintain their comfort and their
feeling of being in control. Eight participants spoke of the
discomfort in labour caused by nausea and vomiting. These
participants did not usually offer a meal to women in labour, but
provided light snacks, including jelly, crackers, cheese, biscuits,
and sandwiches. However, six of the participants described how
nausea and vomiting may be a normal transitional component of
birth. Because of this, they were more concerned about promoting
women’s nutritional or hydration status to prevent discomfort,
stress, and exhaustion as opposed to preventing vomiting.
I would definitely encourage them to eat whatever they want to,
as long as they are comfortable. I guess I would give them
education as well. Lots of women are not very hungry in early
labour and through labour, but just go with what they are
feeling at that time (P.8)
Furthermore, most of the participants indicated that women’s
natural eating and drinking behaviour during labour supports their
emotional and psychological feeling of being in control.
. . . they can feel in control in their labour. And they can feel
that, yes, it is all about things they want to do. Secondly,
obviously, they are going to be uncomfortable, so what is the
point in being starving and hungry? If you are hungry, you
should be able to eat . . . It does make a woman more
comfortable to be allowed to do what she wishes (P.6)
Participants who worked in MGPs and rural hospitals reported
that they were able to offer and provide light meals, sandwiches,
and fresh fruit juice, according to the woman’s comfort needs
compared to those working in private and tertiary birthing units.
6. Discussion
The study found three primary and interrelated factors which
affect midwives’ decision-making in relation to women’s oral
intake during labour. These were very similar to the concepts
raised in the background literature review based on midwives’
capacity for decision making in labour care in general. The study
reflects the literature in its findings that guidelines and policies,
the work environment and model of care, decisions and expect-
ations of other health professionals, and women’s requests, desires
and practices influence midwives’ decision-making.
The participants had learned the evidence for supporting
women’s oral intake during labour as part of their pre-registration
education and other training courses. However, these theoretical
understandings were in some cases different to their actual
midwifery care, as institutional culture and pressure influenced
their behaviour and practice, and in some cases, clinical judgement
and professional experience influenced their recommendations
and care.
The major factor that affected midwives’ decision-making
about oral nutrition during labour in this study was the work
environment, which influenced their capacity for autonomous
practice. Midwives’ level of autonomous decision-making is
known to be different in the various models of care. The midwives
from private hospitals felt obliged to follow the lead obstetricians’
preferences and advice. Such medical dominance is well described
in the literature. Research has shown that low-risk uncomplicated
primipara women who give birth in private hospitals have the
highest chance of having an instrumental birth or caesarean-
section compared to public hospitals [22]. With this increased
intervention in private settings it is reasonable to expect midwives
to be concerned about the increased risk of intervention or
caesarean section, however the dominant reasoning participants
e462 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
gave for their practices in relation to oral intake in private settings
was the obstetricians’ preferences. This finding contrasts with the
midwives in rural settings who had more autonomy to make
decisions about women’s oral intake during labour. These
participants did not recall receiving direction about women’s oral
intake during labour from doctors or their peers. These findings are
consistent with the literature on rural healthcare practice [23],
where midwives in rural areas feel that their autonomy is
recognised, and their decisions are supported by their organisation
[14]. The participants who worked in metropolitan public services
described varied influences on their autonomy to practice. Even
though midwives and obstetricians work together, the final
decision is often made by the medical staff in most settings [24]
and may not consider the woman’s preference as the most
important factor for consideration. This study found that midwives
in MGP model of care, have autonomous responsibilities to make
decisions to look after women. Whilst only two participants
worked in an MGP model, it appears that they are more likely to
make decisions about women’s oral intake during labour
independently, being less directed by obstetric colleagues com-
pared to the midwives who worked in the main public hospital
labour and birthing units. In an obstetric model of care, a hierarchy
of relationships exists which may result in midwives feeling
significant pressure from obstetric control [11,12]. As a result, the
autonomy and empowerment to make decisions regarding
women’s oral intake during labour of these midwives is lower
than midwives who work within a midwife-led care model.
This study suggests that midwifery practice in relation to
women’s oral nutrition during labour is less influenced by
knowledge, evidence, or women’s own choice, and more so by
hierarchical control by obstetricians and experienced midwives,
through experience, beliefs, perceived expertise and compliance.
Knowledge is said to be a considerable factor affecting midwives’
decision-making in clinical situations [25]. Moreover, nursing
practice focuses on an illness model of care with preventative and
curative elements [26]; therefore, midwives who are also nurses
may pay more attention to the risks or side-effects of interventions.
Some participants in this study stated that they accessed up-to-
date evidence-based information to teach students about the
importance of women’s oral intake during labour, however, their
actual practice was different. They described being influenced
more by the institutional expectations, and on maintaining their
work relationships with colleagues and peers than following the
best evidence.
When midwives make a midwifery care judgement, they do so,
based on their past experiences of practice. Positive experiences
engender trust and belief which are matched to current situations,
and this pattern influences midwives’ practice [27]. This study
found that participants’ past professional and personal experi-
ences, both positive and negative, had an impact on their decision-
making. Past clinical and personal experiences has been shown to
affect memory recall, which is connected to decision-making
processes [25]. Midwives tend to justify their care, including their
attitudes and performance, based on their years of experience and
perceived expertise [28]. Nevertheless, years of experience are not
associated with an improvement in decision-making and care [25].
Peers, and in particular, senior midwives were identified as
influential on the participants’ practices. Complicated tensions and
hierarchical relationships between senior and junior midwives still
linger in institutional cultures within healthcare facilities [29].
These cause less experienced midwives to feel conflicted between
what they are allowed or supported to do and the midwifery
philosophies and professional standards and current best evidence
which underpin their practice [28].
This study found that the participants recognised the impor-
tance of government and hospital clinical guidelines/policies to
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promote safe and high-quality evidence-based practice; nonethe-
less, they were not aware of, or not confident with their content.
Clinical guidelines/policies are developed to serve institutional
agendas, concentrating on risk management and safety [30].
Participants described rarely or never referring to clinical guide-
lines and policies. Whilst guidelines existed, this study shows that
it is the institutional cultural practice which continues to be
followed more than guidelines themselves [31].
Participants described wanting to provide woman-centred care
and acknowledged that women have the right to choose their care.
However, this study clearly shows how the complicated work
environments with the power relations between staff and
institutional cultural practice influence women-centred care.
When women are made to feel comfortable, supported, cared
for and enabled to make their own decisions, their expectations of
care can be met [32]. However, the study found that it is sometimes
difficult to satisfy women’s preferences and desires due to clinical
directives of lead care providers and senior staff. In such situations,
the participants spoke of needing to guide women to meet the
directives or negotiate with them to achieve the women’s
expectations, which was identified by some, to be in conflict with
their midwifery philosophies of woman-centred care and profes-
sional autonomy in decision making.
When midwives make decisions about midwifery care, they
need to consider the perspectives of different professionals, the
hierarchy, labouring women’s needs, and the lack of support for
change [33]. It is evident from this study that midwives’ autonomy
and empowerment to make decisions in relation to women’s oral
intake during labour was related mostly to authority in the work
environment.
6.1. Implications for midwifery practice
The findings of this study have implications for midwifery
practice globally. The study provides an understanding of the
factors that influence midwives’ decision-making in relation to
women’s oral intake during labour, and how these factors create
tension. Respectful, evidence-based collaborative practice is vital
for enhancing woman-centred maternity care, ensuring that every
woman is empowered in their maternity care decision making. The
participants indicated that labouring women usually accepted
their lead care providers’ advice; however, women’s expectations
and desires regarding eating and/or drinking may sometimes be
overlooked. The study suggests that midwives should provide
appropriate evidence-based information about oral intake during
labour prior to, or during labour, in order to facilitate women’s
autonomous decision-making. Therefore, ways to enhance mid-
wives’ decision-making processes, translate evidence into practice,
challenge cultural norms as agents of change, and empower them
towards autonomous practice, should be included as part of pre-
service and in-service education.
6.2. Limitations of the study
Several limitations need to be considered when applying the
findings of this study. Even though the participants were employed
in a variety of contexts and models of care, they worked in only two
states of Australia; South Australia and New South Wales. There
were no independent practicing midwives in the study, who may
have a very different experience given the absence of institutional
culture to constrain their practice. The varied method of
communicating with participants for data collection may have
influenced the quality, however the same questions were used, and
all interviews conducted by the same researcher to reduce this
potential. Two respondents were known to the principal research-
er; however, they had never worked together, and their
 M. Tadaumi et al. / Women and Birth 33 (2020) e455–e463
participation was anonymised during transcription and their
participant code unknown to the remainder of the team. Midwives’
experiences and feelings in relation to women’s oral nutrition
during labour are diverse and highly individual; therefore, the
findings might not be reflective of all midwives.
7. Conclusion
This qualitative study, using an interpretive descriptive approach,
has explored factors that influence midwives’ practice in relation to
women’s oral intake during labour. Midwives’ knowledge and beliefs
are developed through their formal education, and professional and
personal experiences. In addition, the work environment, health
systems, models of care, clinical guidelines/policies, and women’s
expectations of care and comfort determined midwives’ decision-
making and behaviours in providing care in relation to labouring
women’s oral nutrition. This study has identified that midwives’
decision-making in relation to women’s oral nutrition during labour
is influenced by complicated environments, the models of care, and
the power relations between clinicians and midwives, more so than
universal, government, or hospital clinical guidelines.
The most significant factor to arise from this study was the
influence of workplace, in particular the institutional culture
which influenced participants’ capacity for autonomy and deci-
sion-making in relation to women’s oral intake during labour. The
findings of this study provide an understanding of midwives’
experiences of women’s oral intake during labour, and the factors
which are linked and create tension in their practice. It is important
for midwives to be aware of these factors which negatively
influence their decision-making processes in order to facilitate
midwives’ autonomy and empowerment.
Conflict of interest
None declared.
Ethical statement
Human research ethics approval was gained from Flinders
University Social and Behavioural Research Ethics Committee.
Funding
None declared.
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