Accepted Manuscript

WHAT WOMEN VALUE IN THE MIDWIFERY CONTINUITY OF

CARE MODEL: A SYSTEMATIC REVIEW WITH META-SYNTHESIS

Noelyn Perriman RM, MM , Deborah Lee Davis RM, PhD ,

Sally Ferguson RM, PhD

PII: S0266-6138(18)30115-3
DOI: 10.1016/j.midw.2018.04.011
Reference: YMIDW 2247

To appear in: Midwifery

Received date: 23 August 2017

Revised date: 26 February 2018
Accepted date: 3 April 2018

Please cite this article as: Noelyn Perriman RM, MM , Deborah Lee Davis RM, PhD ,
Sally Ferguson RM, PhD , WHAT WOMEN VALUE IN THE MIDWIFERY CONTINUITY OF
CARE MODEL: A SYSTEMATIC REVIEW WITH META-SYNTHESIS, Midwifery (2018), doi:
10.1016/j.midw.2018.04.011

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 ACCEPTED MANUSCRIPT

WHAT WOMEN VALUE IN THE MIDWIFERY CONTINUITY OF CARE MODEL: A

SYSTEMATIC REVIEW WITH META-SYNTHESIS

(1) Conflict of Interest - none to declare

(2) Ethical Approval – not applicable
(3) Funding Sources – not applicable

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Noelyn Perriman RM, MM a, b Deborah Lee Davis RM, PhD a, c & Sally Ferguson RM, PhDa .

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a. University of Canberra, University Drive, Bruce, ACT 2617
b. Calvary Health Care Bruce, Haydon Drive, Bruce, ACT 2617
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c. ACT Health, Yamba Drive, Garran, ACT 2605
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Abstract
Introduction: There are a number of qualitative studies indicating
women are more satisfied with a continuity model of midwifery care
however, their experiences have not been understood to gain an overall
picture of what it is they value, appreciate and want in such a model.
A metasynthesis was undertaken in order to examine the current
qualitative literature to gain a deeper understanding of the woman's
perspective as a consumer of maternity care in a continuity model.
Aim: To identify and synthesise research findings presenting
childbearing women's perspectives on continuity of midwifery care.
Methods: A search using key words was undertaken using the following
databases: CINAHL, Cochrane Library, Ovid, Medline, Nursing Reference
Centre and Joanna Briggs Institute. Papers were included if they were

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published since 2006, in English and included qualitative data from
the woman's perspective. The selection process followed that

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recommended by the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA). Quality appraisal was conducted by all
authors using the Critical Appraisal Skills Programme (CASP) tool as a

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screening tool. This allowed for each paper to be appraised to
determine risk of bias.
Findings: Thirteen quality appraised papers published between 2006 and
2016 were found which included qualitative data and were related to

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the woman's experience in a continuity model. Six papers were from
Australia, three in the United Kingdom, two in New Zealand and one in
the United States of America and Denmark. Themes identified included
an overarching concept of the relationship which was underpinned by
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themes of personalised care, trust and empowerment.
Conclusions: The midwife - woman relationship is the vehicle through
which personalised care, trust and empowerment are achieved in the
continuity of midwifery model of care.
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Keywords: midwifery, continuity of care, case-load, consumer

Introduction
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There are a number of quantitative studies indicating that women have improved
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outcomes and are more satisfied with a continuity model of midwifery care
compared with standard hospital maternity care and obstetric-led models of care
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(Kuliukas, et. al., 2016; Sandall, et. al., 2009; Williams, et. al., 2010; Leap, 2010;
Huber, et. al., 2006). Continuity of midwifery care is a multi-faceted model that
includes many elements that might contribute to improved outcomes and
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satisfaction (Soltani & Sandall, 2012) however, we seem to have little

understanding of what women it is that women value within this model of care
(Forster, et.al, 2016). This meta-synthesis was undertaken to compile and
synthesise women’s voices within qualitative research papers to provide a deeper
understanding of women’s experiences of midwifery continuity of care models.

Listening and responding to the service users’ perspective is central to the design
and delivery of quality healthcare services (Clark et. al., 2015). Consumers provide

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a ‘reality check’ that can help healthcare organisations understand how to make
changes to healthcare that are meaningful (Clark et. al., 2015). In Australia,
Standard 2 of the National Safety and Quality Health Service Standards (NSQHS,
2014), ‘Partnering with Consumers’, aims to improve consumer participation in
healthcare services. Consumer participation can range from the basic provision of
information and consumer consultation, to the engagement of consumers and
carers in partnerships with service providers (Britton, 2012). While this engagement
can occur in many ways, healthcare organisations often draw on satisfaction

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surveys to obtain ongoing feedback about a service. In maternity care, these

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satisfaction surveys are often generic and do not provide feedback that is particular

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to maternity services or continuity models of midwifery care. As we have highlighted
in a previous publication, different services also use a variety of tools to measure
satisfaction and this also makes benchmarking of “satisfaction” difficult (Perriman &

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Davis, 2016). Green (2012) sees the patient satisfaction evaluation of care as an
‘exit poll’, and she suggests that the conversation needs to be centred not so much
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on what the woman wants as such, but on what she values in the continuity model.
In order to improve the quality and usefulness of the information gained from
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satisfaction surveys for continuity of midwifery models of care, it is important to

develop tools for measuring satisfaction that are particular to this type of service.
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The first step in this process is to seek a better understanding of what women want
or value in such a service.
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While a number of qualitative studies have contributed to this field of research, to

date women’s experiences have not been assimilated to gain an overall picture of
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what it is they appreciate or want within continuity of midwifery models of care

(Soltani & Sandall, 2012). This paper presents the results of a systematic review
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with meta-synthesis that was undertaken to examine the current qualitative

research literature in order to gain a deeper understanding of the experience from
the childbearing woman’s perspective. The research asks ‘What do women value in
the midwifery continuity of care model?’

Methodology

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A systematic review with meta-synthesis is a process which identifies and assesses

relevant research in qualitative work. Research findings are then combined and re-
analysed allowing for a new interpretation to emerge (Thomas & Harden, 2008). An
increasing number of meta-syntheses are appearing in the nursing and midwifery
literature (Walsh & Downe, 2006). In contrast to the meta-analysis of quantitative
studies, the technique in meta-synthesis is interpretive. By bringing together
qualitative studies in a related area (in this case, women’s experiences of continuity
of midwifery care), the meta-synthesis should be viewed as a process of opening

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up spaces for new insights and understandings to emerge (Walsh & Downe, 2005).

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The synthesis of qualitative data results in the creation of a more comprehensive

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understanding of a concept (Barnett-Page, et. al., 2009). The process comprises of
a systematic review of qualitative research literature with analysis and synthesis of
study findings to generate new understandings of phenomena; in this case

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women’s experiences of continuity of midwifery led care. For the purposes of this
meta-synthesis, continuity of midwifery led care was defined as; a model of care
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which enables a woman to develop a relationship with her known midwife. In
addition, this partnership extends across the continuum of antenatal, labour, birth
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and postnatal phases of childbearing (ACM, 2017).

Search strategy and selection
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A search using the following keywords was undertaken; midwifery, continuity,

women, views, research, qualitative and variations of these terms (e.g. midwi* to
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capture midwives, midwife, midwifery). Boolean operators were used to combine

key words as follows; (midwi* AND continuity AND (woman OR women*) AND
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(view* OR perspective* OR voice*) AND research AND qualitative. A two-stage

process was undertaken which included a search of databases and a ‘snowballing’
technique. ‘Snowballing’ in this context refers to the process of hand searching
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reference lists of relevant articles for additional material. Databases searched

included; CINAHL, Cochrane Library, Ovid, Medline, PubMed, Nursing Reference
Centre and Joanna Briggs Institute. The search for unpublished studies included
the following databases: ProQuest Nursing and Allied Health Source, Trove and
Google Scholar. Papers were included if they were published from 2006, in English
and had a qualitative or mixed method research approach, thus allowing for all
studies with a qualitative element to be included. In addition, studies were included

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if they contained direct quotations from women experiencing continuity of midwifery

led care.

The process of selecting articles to be included in the meta-synthesis was

undertaken initially by the primary author and followed that recommended by
PRISMA (Moher, Liberati, Tetzlaff, & Altman, 2009). After duplicates were removed,
selections proceeded by examination of article title, followed by abstract and then
by a full article review (see Figure 1). Twenty-one full articles were assessed for

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eligibility with eight of these being excluded with reasons (described in Appendix A).

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The remaining articles were assessed for quality initially by the primary author and

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following this in a collaborative meeting by all authors, using the process borrowed
from Smith and Lavender (2011). The process used involves a summary of each
article using a table format and an appraisal for quality (Table 1). The table

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headings addressed the aims (e.g. to explore relational model in decision making –
continuity), theoretical framework (e.g. grounded theory), design (e.g. in depth open
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ended interviews), context (e.g. major public hospital or birth centre), sampling
strategy (e.g. purposeful, randomised), participant characteristics (e.g. >18 years @
34 – 37 weeks), data collection methods (e.g. interviews recorded, transcripts
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coded using NVivo.) and analytic approaches (e.g. descriptive phenomenological

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method or thematic analysis) of each included paper. The final column in the table
presents the quality rating which was determined using the process described
below.
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Quality appraisal was initially conducted by all authors independently using the
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CASP Qualitative Research Checklist tool as a screening tool. The CASP tool
(Ertmer & Stoel-Gammon, 2008), allowed each paper to be appraised by the
researchers to determine risk of bias. The CASP tool has ten questions canvassing
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three main areas: internal validity, results and external validity. The first two
questions are screening questions and the remaining questions can be recorded as
“yes”, “no” or “can’t tell.” Each included paper was assessed systematically using
the ten CASP questions. Following this, a joint meeting of authors was held to
discuss and come to an agreement on the quality of each paper. A more extensive
assessment followed using twelve essential criteria for appraising the quality of
qualitative research developed by Walsh and Downe (Walsh & Downe, 2006).

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Following independent review the researchers met to discuss assessments and any
disagreements were resolved by discussion to reach consensus. Papers were
graded A to D depending on the degree to which they met the quality criteria, with
any paper graded as a D to be excluded. Only one paper fell into this category;
Boyle et. al., 2016. This paper was excluded due to concerns regarding internal and
external validity. Table 1 describes the characteristics of studies included in meta-
synthesis and presents their assessment grade.

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Meta synthesis

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The process of synthesising findings from the thirteen included papers was
undertaken by identifying themes in the combined data. The identification of themes
involves determining, examining and recording patterns within data that are

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associated with the overall research question (Smith & Lavender, 2011). The
analysis involved a process of familiarity with the narrative, generation of initial
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themes, subsuming initial themes into cluster themes and the development of a
core, overall concept that summarises the themes and their relationship to each
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other. The first author led the analysis though all authors were involved through
regular discussions where interpretations were interrogated for their veracity in
relation to the data and the researchers’ own potential biases were examined.
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The four themes identified with meta-synthesis were: midwife-woman relationship

(overarching theme), personalised care, building of trust and empowerment. Table
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2 describes the development of themes and overall core concept.

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Thirteen studies were identified for inclusion, with the majority of six undertaken in
Australia. The remaining studies were conducted in the United Kingdom, Denmark,
New Zealand and the United States of America. The research designs employed
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were mixed methods or qualitative descriptive method. Overall, three data collection
methods were used and these were surveys (Williams, et.al, 2010; Homer, et.al.,
2012; Grigg, et.al., 2015), focus groups (Homer, et .al., 2012; Grigg, et.al., 2015)
and in-depth or semi-structured interviews (Doherty, 2010; Leap, et. al., 2010;
Jenkins, et. al., 2015; Jepsen, et. al., 2017; Dahlen, et. al., 2010; Huber & Sandall,
2009). The surveys were usually posted to the women who consented to being
included in the research project. The interviews were in most cases face to face, in-

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depth or semi-structured, using an open-ended questioning method. The interviews

or surveys were conducted in the postnatal period, from 6 weeks to 6 months
postpartum, which ensured that women were able to reflect on their complete
midwifery care experience which included antenatal, intrapartum and postnatal
care. Most studies had small sample sizes with the exception of those studies using
a mixed methods design. The majority of women were recruited in the antenatal
period. The participants included women aged 18 to 40 years and there was a
mixed cohort of primiparous and multiparous women. In nine papers purposive

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sampling was employed in order to ensure diversity in participant backgrounds

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(Kuliukas, et. al., 2016; Doherty, 2010; Huber & Sandall, 2009; Dahlen, et. al.,

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2010; Leap, 2010; Huber, et. al., 2006; Jenkins, et. al., 2015; Jepsen, et. al., 2017).
In the majority of included studies thematic analysis was employed as the method
of analysing data. This is recognised as the most often used method to analyse

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data in qualitative research (Thomas & Harden, 2008).

The overarching theme that emerged was the relationship between the midwife and
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the woman. Analysis revealed that underpinning this overarching theme were
themes of personalised care, trust and empowerment (see Figure 2 which
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illustrates the relationship between themes).

Midwife-woman relationship
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In a continuity model of care the midwife-woman relationship is important to the

childbearing woman.
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I had built a relationship with my midwife and (she) knew my strengths and
concerns. (Williams et. al., 2010).
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Participants recognised that the relationship took time to develop, building over the
continuum of the pregnancy, birth and puerperium. The relationship has a quality
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that sets it apart from other service-user-professional relationships in that it was

described as close and friendly;

They are so smiling and laughing and not just strict professionals in clean
white uniforms (Jepsen, et. al., 2017).

I looked forward to my visits because I was coming to visit friends (Homer,

et.al, 2012).

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Or as a partnership;

I felt a partnership with my midwives- it began during pregnancy and peaked

during labour and birth…… (Doherty, 2010)
In a partnership relationship women are involved in decision making;
She always made me feel involved in decision-making … (Doherty, 2010).

Importantly women felt “known” by their caregiver;

They understand you a little more ‘cause they’ve got to know you… (Jenkins,

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et. al., 2015).

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…[they] know your story and why you are one of those [people] who asks
questions all the time… (Homer, et.al, 2012).

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This is comforting for childbearing women during labour and birth in particular;

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Having the same midwife is a huge bonus. You get to know each other a bit
more on a personal basis which is a comfort in a personal situation such as
labour (Williams et. al., 2010).
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In this relationship open communication and equality are important components that
inevitably facilitate the pregnancy, birth and postnatal journey. The midwife-women
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relationship is the vehicle through which trust is built, personalised care is provided
and the woman feels empowered.
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Personalised Care

With the development of a relationship where the midwife gets to know the
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childbearing woman, maternity care is experienced as personalised;

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We did choose it [caseload midwifery], not only because it was close to

home but it was a really personal experience. Like at the start I sort of just
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didn't really want to be just a random person in a hospital having a baby. I

really wanted to have that sort of care ... somebody that is my go to person
and any appointments I see this person, they know me, I know them. So that
was something that really was good for us (Jenkins, et. al., 2015).

Knowing the woman mean that the midwives understood what she wanted for her
pregnancy labour and birth;
My midwife was fantastic and I felt so supported by her and confident that

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she understood me and what I wanted for all parts of my pregnancy, labour,
birth etc. (Grigg, et.al., 2015).

When midwives gave personalised care women felt special and unique;
They [the midwives] also make you feel that you’re very special, it’s just your
birth, whereas when you just see there are just hundreds of people giving
birth every day and you’re just this kind of one in one out person …..For me it
just meant that I felt more confident…it was a nice and secure feeling you

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know, that they would be with me, whichever way it went (Huber & Sandall,

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2006).

I felt so important here and I never felt rushed…….for once I actually felt it

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was about me (Homer, et.al, 2009).

With a personalised approach to care women felt “cared for” and this along with
continuity was comforting to them; US
You just find instant comfort, and you know that no matter what happens
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they’ll be there. That was really important. I think that’s the biggest thing: that
you’re not stuck with somebody that doesn’t care, or changing people, not
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tons of different faces. You’ve got the same people all the way through (Leap,
et. al., 2010).
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In their comments, women highlighted what they felt were the benefits of the
continuity model with affirmation regarding the relational aspect of the continuity
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model. Womens views included;

…feeling comfortable with the midwives, feeling in control, empowered,
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receiving personalised care and support and feeling special (Williams et. al.,
2010).
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Within the context of relationship and with personalised care came the development
of trust.

Development of Trust

Continuity of care facilitates the development of trust and women recognised that
this takes time to develop;
We trust her…and that’s all from building a relationship with her every time. I
don’t think you can rush something like that. You gain trust from knowing

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somebody and feeling comfortable with her (Huber et. al., 2006).

Women described how they had their own wishes and desires for their pregnancy,
labour and birth;
The midwife had the birth plan with her so I trusted her to have read that and
she did... she knew what we wanted (Kuliukas, et. al., 2016).

However, when the course of events deviated from what was hoped for, women
were trusting of the midwife and the advice they provided;

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Having the trust with Candice [the midwife] she would only recommend

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something like that if she absolutely had to (Noseworthy, et. al., 2013).

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She knows what I want, and if she says we have to do something else, I know,
that she will have had in mind what I initially wanted, but that we have to

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change now. I trust her completely (Jepsen, et. al., 2017).

Trust is an important element in the continuity of care relationship that women

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value. In a continuity of care relationship that facilitates personalised care and the
development of trust, the childbearing experience is described by women as
empowering.
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Empowerment
ED

Empowerment is seen when women and their midwife share information which
enables the woman to take the lead in decision making about the care which is
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provided. The role of confidence is also seen as a significant enabler;

I found it very empowering. It made me very confident that I could do anything

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basically (Dahlen, et. al., 2010).

Confidence was developed through interactions with midwives that reinforced

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women’s strength and highlighted their baby’s wellbeing;

The midwives encouraged me a lot, they talked to me a lot and made me feel
that I was OK, and I’m strong, and the baby is happy (Leap, et. al., 2010).

A woman who had a previous stillbirth found confidence was built through positive
affirmation;

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And at the end of each antenatal visit she’d say, ‘Oh that’s a happy baby’, And
that made a really, really significant difference to how I felt, just that positive
affirmation, you know (Leap, et. al., 2010).

One woman recalling her labour stated;

If you give a woman the kind of support I had, she can do a lot! (Doherty,
2010).

Feeling empowered is an important outcome of the continuity of care relationship

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that women value. This is achieved by a relationship that facilitates personalised

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care and the development of trust.

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Synthesis summary

The unique finding of this meta-synthesis can be summarised by the following

sentence;
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In continuity of midwifery models of care, the midwife – woman relationship is the
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vehicle through which the childbearing woman experiences personalised care, trust
and empowerment.
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Discussion
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There is a lack of robust data to inform health care providers around models of
care, and in particular the reasons behind the choices that women make (Rogers,
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Harman, & Selo-Ojeme, 2011). Continuity of midwifery care is a multi-faceted

phenomenon and we know little about what women value within this model of care.
This meta-synthesis was undertaken to compile and synthesise women’s voices
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within qualitative research papers to provide a deeper understanding of women’s

experiences of a midwifery continuity of care model. The meta-synthesis describes
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the key components of the continuity of midwifery care model that women value;
the midwife-woman relationship, personalised care, building of trust and
empowerment.

The thirteen included papers differed in their research approach and design, but
essentially assist, through the use of narrative, to develop an understanding of what
it is that women value in a midwifery continuity of care model. The midwife-woman

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relationship is a vital component. Hodnett (2002) explored women’s satisfaction

with the experience of birth through a sytematic review process. Four factors were
identified that far outweighed traditionally important variables. Two of these directly
relate to the personalised relationship, in that the influence of interventions and pain
are less powerful or important to the woman ‘as the influence of the attitude and
behaviours of the caregivers’ (Hodnett, 2002). The aim of midwifery care according
to Hunter et. al. (2008) is essentially to keep birth as normal as possible, and the
essential ingredient needs to be the ‘caring relationship’.

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“Relational continuity” can be understood as a therapeutic relationship between the
health professional and healthcare recipient which results in “accumulated

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knowledge of the patient and care consistent with the patient's needs” (Burge et. al.
2011 p. 125). This reflects the findings of our study where the relationship was

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described as the vehicle through which many of the benefits of the continuity of
midwifery care model were achieved. The importance of “relational continuity” is
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recognised also in primary healthcare settings such as general practice where it is
associated with improved communication, uptake of health promotion activities,
reduced diagnostic testing and emergency department utilisation and admissions
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(Burge et. al., 2011). Care that is “consistent with the patient’s needs” is included
in the definition of relational care for Burge et. al. (2011) and this relates to our
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theme of “personalised care”.

In our study “personalised care” describes an approach that shows concern for the
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individual, taking into consideration their wishes and desires. This is reflective of
“patient centred care” as defined by the Institute of Medicine; “respectful of and
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responsive to individual patient preferences, needs, and values, and ensuring that
patient values guide all clinical decisions.” (2001, p. 6). Patient centred care results
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in enhanced patient safety, improved healthcare outcomes, improved patient

wellbeing, reduced health care costs and according to Epstein et. al. (2010) “helps
bridge differences among physicians and patients in health beliefs, race, ethnicity,
and culture and mitigates disparities in prevention and treatment” (p. 1492). This is
echoed by Huber et. al. (2006) who considers that continuity of midwifery care
enables the 'bridging of life-worlds’ between the caregiver and childbearing woman
(Huber et. al., 2006).

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Our study identified “trust” as a key component of the midwifery continuity of care
model valued by women. The development of a relationship between the midwife
and woman facilitated the development of trust. Trust is a multifaceted
phenomenon that can be understood as both process and outcome and is an
essential element of all healthcare encounters. In a systematic review of qualitative
studies focusing on the patient experience of trust from a nursing perspective,
Rørtveit et. al. (2015) found that patients’ experiences of trust depended on a
number of factors including the nurse’s knowledge and commitment to developing

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the relationship. In maternity another systematic review by Swedish researchers

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identified trust as one of six central concepts in the midwife-woman relationship

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(Lundgren & Berg, 2007). In this study trust in the midwife represented one facet of
trust from the childbearing woman’s perspective whilst trust in their own abilities
was another. This is reminiscent of our theme of “empowerment”.

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Empowerment is a concept frequently used in midwifery but often without clear
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definition. The definition arrived at by Hermansson et. al. (2011) using concept
analysis defines empowerment as a “dynamic and social process” that involves the
development of a trusting relationship that ultimately “enhances the childbearing
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couples’ own abilities” (p.815). Our study also highlighted how important the
midwife “building confidence” in the childbearing woman was to her empowerment.
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In a study with midwives Browne et. al. (2014) identified a number of strategies that
midwives use in the antenatal time to build women’s capacity for childbirth including
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reframing the woman’s body as a “reassuring body”. In this; “midwives strategised

to normalise pregnancy and women's related concerns by instilling confidence in
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each woman” (p. 423). Similarly, Davis and Walker (2010) found that midwives
“…generally work to bolster the woman's confidence in her ability to grow, birth and
parent her baby. They do this by affirming the normality of childbirth and the fitness
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of women's bodies for the task of childbearing” (p. 605). In our study women
experience this as empowerment.

Implications for practice

This meta-synthesis draws together and re-analyses qualitative data from the
childbearing womens’ perspective, on their experiences of continuity of midwifery
care. The core, overall concept arrived at through this process is that “the midwife-

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women relationship is the vehicle through which trust is built, personalised care is
provided and the woman feels empowered”. While we know that continuity of
midwifery care results in improved clinical outcomes and greater satisfaction with
maternity care, we do not know what elements of this model are important to
women. This study has identified that the relationship between the childbearing
woman and midwife is central and through this additional benefits are realised;
trust, personalised care, and empowerment. This has implications for practice and
maternity service development. Relational continuity is a critical component of

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continuity of care midwifery services and midwives should prioritise the

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development of a relationship with the women in their care. Employers and service

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providers should recognise the importance of the development of such a
relationship and provide the resources and environment necessary to enable this.

Limitations
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This study makes an important contribution to the literature on continuity of
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midwifery care however it has some limitations. Secondary analysis of research
papers relies heavily on the quality of included studies and while all included
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studies were graded A-B, they each had some individual weaknesses. In addition,
analysis in a meta-synthesis can be challenging as each included study (while
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meeting the inclusion criteria for this systematic review) was undertaken for a
purpose with distinct aims that did not necessarily align exactly with the aim of this
study, which was to broadly clarify women’s experiences of continuity of midwifery
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care.
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Conclusions
Drawing on the words of women experiencing continuity of midwifery care, this
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systematic review and meta-synthesis illuminates the components of this model of

care that are important to women. Women describe how the relationship with the
midwives is important and how this gives rise to the development of trust,
personalised care and empowerment. This has important ramifications for clinical
practice and service development.

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Disclosure of interests
Nil to disclose.

Contribution to authorship

NP reviewed the papers, conducted the synthesis and wrote the first draft of the
article. DD conceived the idea of a meta-synthesis, reviewed and analysed papers.

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SF reviewed and analysed papers. All authors contributed to revision and editing of
the manuscript.

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Details of ethics approval

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As this is a review of the literature, no ethical approval was required.

References
AN
Australian College of Midwives. https://www.midwives.org.au/know-your-midwife-
benefits (Accessed 22/5/2017)
Australian Council of Healthcare Standards. 2014. Available at
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Figure 2. Relationship of concepts

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Personalised care Development of trust Empowerment

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“in control”

Author
(Country)
Study Aim Methodology
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Design Context Sampling
Strategy
Sample
size
Participant
characteristic C
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s m
Noseworthy 1 To explore Ontological & Audio Urban Self-selected 8 >18 years @ Ant
(NZ) relational model Philosophical recorded setting following midwives 34 – 37 weeks rec
in decision interviews In NZ presentation /women re
making – (antenatal of information. pairs. (d
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continuity and re
postnatal). ma
o
p
P
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i
und
h
m
rese
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Williams 2 Evaluate Mixed method Postal Major public Randomised 174 87 Se

(AUS) mother’s survey hospital in women primiparous que
satisfaction with undertaken NSW, and 87 (5 p
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caseload. linked to Australia multiparous sc

clinical women. All
outcomes. low-risk q
(ACMI, 2004)
Kuliukas 3 Describe overall Descriptive Interview at Birth Centre Sampling was 15 Women In
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(AUS/WA) labour and birth phenomenologic 8 weeks in WA, purposeful. women transferred re
experience for al design to postpartum Australia during labour tr
women capture ‘lived with Birth co
transferred out experience’. Centre
of a Birth midwife
Centre. (English
speaking).
Homer 4 Research role of Multi-method Survey and Various Randomised 28 Pregnant A
(AUS) midwives from interviews settings in women Women
woman’s AUS involved in S
perspective continuity maternity p
settings. activism.
Each state
and territory
represented.
Doherty 5 Explore the Phenomenologic In depth Nurse- Purposive 12 (data 28 – 40 years
(USA) experience of al Approach open ended midwifery sampling saturation Postnatally rec

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midwifery care interviews practices in achieved) over a 3 tra

from the point of New month period. v
view of England, In
midwifery USA we
clients. min
Huber 6 Explore the Mixed method Non London, UK Purposive 14: 10 21 – 40 years 6 in
(UK) relationship participant sampling to women from diverse 4-6
between one-to- observation maximise and 4 backgrounds. birth
one model of and semi- variation in midwives mo
maternity care structured demographic
and the creation interviews
of calm
Homer 7 Evaluation of Mixed method Focus Malabar, Women 353 40% Cli
(AUS) Malabar groups, Sydney, booked in Aboriginal and col
Community tape Australia 2007-2008. Torres Strait poin
Midwifery Link recorded, Purposive to Islander Fo
Service from analysed ensure incl

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perspective of verbatim, inclusion of pas
ATSI women. analysed women who th

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qualitatively had diverse
experiences.
Dahlen 8 To explore first Grounded theory Face to face Sydney, Sampling was 19 19-37 years 2

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(AUS) time mothers in-depth Australia purposeful pre
experiences of interviews th
birth at home with open we
and in hospital ended
questioning In
(Audio- la

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eristics of studies included in meta-synthesis (continued)

9 Exploring Qualitative Face to face London, UK Purposeful 10 17-38 years 60 minutes Thematic
relationship descriptive semi- heterogeneity analysis
between methodology structured sampling
continuity and in-depth
reduced interviews.
pharmacological
pain relief.
10 Exploring Care Qualitative In depth London UK Purposeful 10 21 – 40 years Not revealed Thematic
relationships interviews until (7 multi’s analysis
between @ 36/40 at saturation and 3
women, home. reached primips)
midwives and
birth partner
11 Explore womens Mixed methods 8 focus Christchurch 2310 women 608 incl. 25 – 40 years. 60 – 90 Thematic

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birthplace prospective groups (4-6 NZ were sent 37 focus minutes analysis
decision-making cohort design in each invitations to group and
for well (‘low group). A participate, 571

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risk’) women, six week 30% joined completed
intending to give postpartum the study. a survey
birth in either an survey (571 Focus Groups

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obstetric-led women) and were a self-
maternity a survey at selected sub
hospital or a 6 months group. The
free-standing postpartum earthquake
midwifery-led Survey delayed
primary level included uptake -

12
maternity unit.

To gain an Qualitative
closed
questions
and open
text.
In-depth NSW -urban
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extended
from 3/2010 –
2/2011.
Purposive 53 women 18–44years Interview 30 – Thematic
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understanding of semi- (17%), variation 45 minutes analysis
how women structured regional sampling -
conceptualise interviews (28%), rural broad range
continuity of (40%), of
maternity care remote perspectives.
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(15%)
13 Follow, explore Ethnography Data North Purposive 10 The woman Field Max van
and elaborate using generated Denmark variation couples. and her observations Manen’s
women’s and by sampling - 5 primips partner followed by description of
their partners’ observation broad range and 5 receive semi- thematic
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views of followed by of multi’s antenatal care structured analysis (a

caseload interviews perspectives. no more than interviews (30- selective
midwifery. 40km from the 50 mins) highlighting
hospital. approach).
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Table 2: Initial theme and final themes

Initial themes Relevant papers Core overall
Cluster themes
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1, 2, 3, 4, 5, 6, 7, Midwife-woman The midwife-

Open
12 relationship women
communication,
relationship is the
presence, feeling
vehicle through
at ease,
which trust is built,
partnership.
personalised care
1, 2, 4, 5, 6, 7, 10, Building of trust
Comfort, feeling is provided and the
13
secure, safe. woman feels

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In control, self- 2, 4, 5, 6, 8, 9,10 Empowerment empowered.

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esteem, strength,

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confidence.

3, 4, 6, 7, 9, 11 Personalised Care
Feeling special,
feeling important,
being understood.
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