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Issue: Injury to the perineal tissues during childbirth is a frequent occurrence with most women likely to experience perineal injury during a first birth which, in some cases, can lead to significant long-term morbidity. The techniques used to minimise perineal injury are frequently termed 'hands on' and 'hands poised' or 'hands off'. These terms are often undefined and used inconsistently in the literature, making it difficult to identify the best available evidence to inform midwifery practice., Aim: This study aimed to answer the research questions: What do midwives do to minimise perineal injury during birth and what influences their decision-making?, Methods: An ethnographic study was undertaken during 2016 in a maternity unit in the southeast of England. Data were collected through participant-observation, ethnographic and semi-structured interviews and analysed using thematic analysis, informed by the pedagogic theory of threshold concepts., Findings: 31 midwives participated in the study. Evidence-based decision-making to minimise perineal injury during birth was identified as a complex concept. Within the context of threshold concept theory, three main themes were identified that contributed to the complexity: troublesome language, troublesome knowledge, and troublesome environments., Conclusions: Midwifery decision-making in the context of minimising perineal injury during birth is more varied and conceptually complex than has been previously described. Identification of the various aspects of troublesomeness in this context suggests that this element of practice is a midwifery threshold concept. Addressing this within midwifery curricula and practice education to enable evidence-based decision-making is important., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: To explore midwives' and parents' perceptions and actions as well as the culture surrounding the first hour after the birth of a baby - the golden hour., Design: Short-term ethnographic study, which included observations, informal interviews and focus group interviews. Thematic network analysis was used to analyse the data., Setting: Two birthing hospitals in Finland., Participants: The first hour following 16 births was observed and informal interviews of attending midwives (n = 10) and parents (n = 3 couples and n = 6 mothers) were conducted to supplement the observations. The 16 cases included both primiparous (n = 8) and multiparous (n = 8) women, as well as vaginal (n = 12) and elective caesarean births (n = 4). Furthermore, two focus group interviews with midwives (n = 9) were conducted to deepen the understanding., Findings: The over-arching theme Unchallenged hospital 'rules' comprised the two main themes of Safety-driven support by midwives and Silent voices of the parents. The hospital guidelines and practices guided the first hour, unchallenged by parents and midwives. Based on the guidelines, all the babies were given skin-to-skin contact early but not immediately. Midwives strictly followed the guidelines and performed many activities with the mothers during the first hour. Embedded power was present: midwives were in control but tended to listen to the parents. Although the mothers displayed a strong need to be close to their babies, their voices were silent in the units. The parents' compliance with midwives and parents' intense focus on the baby strengthened the midwives' embedded power., Key Conclusion: Care culture in birthing units was 'rule-based' and the guidelines and practices sometimes inhibited uninterrupted skin-to-skin contact without questioning. The golden hour was mainly controlled by the maternity care staff., Implications for Practice: Re-evaluation of hospital guidelines should enable more woman- and family-centred care. The golden hour is unique to families, and unnecessary separation and interventions should be avoided., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: Many women experience urinary incontinence (UI) during and after pregnancy. Pelvic floor muscle exercises (PFME) can prevent and reduce the symptoms of UI. The objective of the study was to explore challenges, opportunities and concerns for women and health care professionals (HCPs), related to the implementation of PFME training for women in current antenatal care., Design: An ethnographic study design was used. Researchers also formed and collaborated with a public advisory group, consisting of seven women with recent experiences of pregnancy, throughout the study., Participants: Seventeen midwife-woman interactions were observed in antenatal clinics. In addition, 23 midwives and 15 pregnant women were interviewed. Repeat interviews were carried out with 12 of the women postnatally. Interviews were also carried out with other HCPs; four physiotherapists, a linkworker/translator and two consultant obstetricians. Additional data sources included field notes, photographs, leaflets, policy and other relevant documents., Setting: Data were collected in three geographical areas of the UK spanning rural, urban and suburban areas. Data collection took place in antenatal clinics, in primary and secondary care settings, and the majority of women were interviewed in their homes., Findings: Three broad and inter-related themes of "ideological commitment", "confidence" and "assumptions, stigma and normalisation" were identified. The challenges, opportunities and concerns regarding PFME implementation were explored within these themes., Conclusions and Implications for Practice: Although HCPs and some women knew that PFME were important, they were not prioritised and the significant benefits of doing PFME may not have been communicated by midwives or recognised by women. There was a lack of confidence amongst midwives to teach PFME and manage UI within the antenatal care pathway and amongst women to ask about PFME or UI. A perceived lack of consistent guidelines and policy at local and national levels may have impeded clear communication and prioritisation of PFME. Furthermore, assumptions made by both women and midwives, for example, women regarding UI as a normal outcome of pregnancy, or midwives' perception that certain women were more likely to do PFME, may have exacerbated this situation. Training for midwives to help women in the antenatal period to engage in PFME could address challenges and concerns and to help prevent opportunities for women to learn about PFME from being missed., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Providers' adherence to case management protocols can affect quality of care. However, how and why protocols are adhered to by frontline health workers in low- and middle-income countries is not always clear. This study explored midwives' adherence to national postnatal care protocols in two public hospitals in Southern Ghana using an ethnographic study design. Ninety participant observations and 88 conversations were conducted over a 20-months period, and two group interviews held with the midwives in the two hospitals. Data was analysed using a grounded theory approach. Findings: Midwives collectively decided when to adhere, modify or totally ignore postnatal care protocols. Adherence often occurred if required resources (equipment, tools, supplies) were available. Modification occurred when midwives felt that strict adherence could have negative implications for patients and they could be seen as acting 'unprofessionally'. Ignoring or modifying protocols also occurred when midwives were uncertain of the patient's health condition; basic supplies, logistics and infrastructure needed for adherence were unavailable or inappropriate; or midwives felt they might expose themselves or their clients to physical, psychological, emotional, financial or social harm. Regardless of the reasons that midwives felt justified to ignore or modify postnatal care protocols, it appeared in many instances to lead to the provision of care of suboptimal quality. Conclusion and recommendations: Providing clinical decision-making protocols is not enough to improve mother and new born care quality and outcomes. Faced with constraining conditions of work, providers are likely to modify guidelines as part of coping behaviour. Addressing constraining conditions of work must accompany guidelines. This includes adequate risks protection for health workers and clients; and resolution of deficits in essential equipment, infrastructure, supplies and staffing., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Women can face opposition when exerting autonomous decision-making regarding their birth choices, particularly when the decisions involve going against medical advice and/or outside of national guidelines. Termed 'unconventional birth choices', some research has explored women's reasons and experiences of making such choices, but less is known about the midwives caring for them., Objectives: To synthesize existing qualitative literature on the views, attitudes, and experiences of midwives caring for women who make unconventional birth choices., Methods: A systematic search and meta-ethnography informed by Noblit and Hare and Schutz was undertaken. Eight databases were searched using predetermined search terms, alongside author, reference, citation chasing, and hand searching. Searches were conducted in July 2016 and updated in October 2017. Qualitative studies published since 1993 in English were included. Included studies were subjected to quality appraisal, conducted independently by two reviewers. Analysis was informed by the interpretative meta-ethnography methods., Main Results: Five studies met the inclusion criteria. Eight subthemes emerged. These resulted in three higher level interpretative themes emerged: perceptions of women's decision making, conflicting tensions as caregivers, ways of working with-woman., Conclusions: Midwives can play a pivotal role in ensuring that respectful maternity care includes supporting women in their birthing decisions. Whilst limited research has been undertaken in this area, available insights suggest that midwives' views in this area are situated along a spectrum from 'willingly facilitative' to 'reluctantly accepting'. Views were influenced by context, as well as prior philosophies and values. While further research is needed, this study offers insights into the challenges women can face in seeking unconventional birth choices if they require support from midwives to do so., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Accurate terms aid clarity in thinking and prevent confusion. In the infant feeding field 'normal' can be ambiguous as biologically normal may not equate with culturally normal in a given time or place. Similarly, the use of the term 'intervention' is appropriate if a recommended practice is not perceived as 'normal' to that culture., Objective: This article explores the meaning of 'normal' in the context of infant feeding, since mothers may not perceive breastfeeding as 'normal' when this differs from the experience in communities in which it is considered unusual., Methods: Historical and recent sources were used to explore the effect of culture and established practice on perceptions of what is 'normal'., Discussion: Iceland and several regions of Europe are used as examples of long-term abandonment of breastfeeding during the late Medieval and Early Modern periods and the 19th century. Ireland, the United Kingdom and the United States are discussed in relation to fluctuations and declines in breastfeeding prevalence in the 20th and 21st centuries. The rôle of science and the rise of mother-support groups for breastfeeding, interventions to promote breastfeeding, and the possibility of cultural change, are also discussed., Implications for Practice: Culture influences the perception of what is 'normal' and where a culture has abandoned breastfeeding, or where it is in decline, women are unlikely to view it as the normal way to feed an infant. A more appropriate use of language is recommended, describing breastfeeding as 'biologically normal' or 'physiologically normal', as it is not always, and has not always been, culturally normal. In this context initiatives to improve breastfeeding rates can correctly be termed 'interventions'., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To discuss the concept of 'transcendent birth', an as yet poorly articulated and under recognised psychosocial wellness phenomenon of childbirth., Design: an auto-ethnographical examination of the primary authors' journaled experiences as a student midwife and childbearing woman., Setting: three maternity care units in South Eastern Australia as well as the home of the primary author., Findings: The phenomenon of transcendent birth is linked with physiologic birth. Maternity care can hinder or facilitate physiologic birth, and therefore transcendent birth., Key Conclusions: Transcendent birth is more likely in maternity care models which value the childbearing woman and physiologic birth., Implications for Practice: Women's access to transcendent birth is demarcated by women's position in society, cultural knowledge of transcendent birth and the valuing of transcendent birth as a maternity care outcome., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To explore midwifery one-to-one support in labour in a real world context of midwife-led birth environments., Design: Ethnographic study. Data was collected from 30 observations inside and outside the birth environments in three different birth settings. Semi-structured interviews were completed following the births with 29 low-risk women and 30 midwives with at least one year labour support experience to gain their perspectives. Twenty-seven maternity records were also analysed., Setting: An alongside midwife-led unit, freestanding midwife-led unit and women's homes in England., Findings: Six components of care were identified that required balance inside midwife-led birth environments: (1) presence, (2) midwife-woman relationships, (3) coping strategies, (4) labour progress, (5) birthing partners and (6) midwifery support. Midwives used their knowledge, experience and intuitive skills to synchronise their care for the six components to work in balance. Balancing of the six components have been translated into continuums representing the labour care and requirements., Conclusion and Implications for Practice: Midwifery one-to-one support in labour is more than a ratio when translated into clinical practice. When the balance of the six components were tuned into the needs of women, women were satisfied with their labour and birth experience, even when it did not go to plan. A one midwife to one woman ratio should be available for all women in labour., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: to explore Malawian midwives decision making when caring for women during the first stage of labour in the hospital setting., Design and Methods: this focused ethnographic study examined the decision making process of 9 nurse-midwives with varying years of clinical experience in the real world setting of an urban and semi urban hospital from October 2013 to May 2014.This was done using 27 participant observations and 27 post-observation in-depth interviews over a period of six months. Qualitative data analysis software, NVivo 10, was used to assist with data management for the analysis. All data was analysed using the principle of theme and category formation., Findings: analysis revealed a six-stage process of decision making that include a baseline for labour, deciding to admit a woman to labour ward, ascertaining the normal physiological progress of labour, supporting the normal physiological progress of labour, embracing uncertainty: the midwives' construction of unusual labour as normal, dealing with uncertainty and deciding to intervene in unusual labour. This six-stage process of decision making is conceptualised as the 'role of cue acquisition', illustrating the ways in which midwives utilise their assessment of labouring women to reason and make decisions on how to care for them in labour. Cue acquisition involved the midwives piecing together segments of information they obtained from the women to formulate an understanding of the woman's birthing progress and inform the midwives decision making process. This understanding of cue acquisition by midwives is significant for supporting safe care in the labour setting. When there was uncertainty in a woman's progress of labour, midwives used deductive reasoning, for example, by cross-checking and analysing the information obtained during the span of labour. Supporting normal labour physiological processes was identified as an underlying principle that shaped the midwives clinical judgement and decision making when they cared for women in labour., Key Conclusions and Implications for Practice: the significance of this study is in the new understanding and insight into the process of midwifery decision making. Whilst the approach to decision making by the midwives requires further testing and refinement in order to explore implications for practice, the findings here provide new conceptual and practical clarity of midwifery decision making. The work contributes to the identified lack of knowledge of how midwives working clinically, in the 'real world setting. These findings therefore, contribute to this body of knowledge with regards to our understanding of decision making of midwives., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Aim: to evaluate the ISeeYou project that aims to equip first year Bachelor midwifery students to support them in their learning of providing woman-centred care., Methods: the project has an ethnographic design. First year midwifery students buddied up to one woman throughout her continuum of the childbirth process and accompanied her during her antenatal and postnatal care encounters. Participant-observation was utilised by the students to support their learning. The Client Centred Care Questionnaire (CCCQ) was administered to collect data about women's care experiences. The project was evaluated using the SWOT model., Main Findings: 54 first year students completed the project and observed and evaluated on average eight prenatal visits and two postnatal visits. Students gained insight into women's lived experiences during the childbirth process and of received care throughout this period. Students reported that this was meaningful and supported and enhanced their comprehension of women-centred care. Logistic issues (lectures, travel, time) and being conscious of their role as an 'outsider' sometimes constrained, but never hindered, the students in meeting the requirements of the project. Overall, the project provided students with opportunities to expand competencies and to broaden their outlook on midwifery care., Conclusion: the project offers students unique and in-depth experiences supporting and augmenting their professional competencies and their personal, professional and academic development., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: this study offers insight into how women perceive childbirth pain and how they make decisions about whether to use an epidural during childbirth in the low technology context of the Netherlands maternity care system., Design: ethnographic research consisting of participant observation at births and prenatal and postnatal appointments; semi-structured interviews with a sample of recently post-partum women; coding and triangulation of data to determine key themes in the interviews., Setting and Participants: the study was carried out with participants in thirteen urban cities around the Netherlands. The 40 post-partum women had lived in the Netherlands for at least 10 years prior to participation in the study, spoke English proficiently, and had a vaginal birth within the past 18 months. Additionally, participant observation occurred in midwifery practices., Findings: analysis of the interviews revealed three key themes: first, participants perceive childbirth pain as "natural" and positive, and approach its management through non-medical birth methods; second, participants prioritize autonomy in childbirth which they see as something they can "do on [their] own" without pain medication; and third, participants' decisions about using an epidural was supported by professional advice and social connections, such as friends and family members., Key Conclusions and Implications for Practice: women's conception of pain is central to decisions about childbirth in the Netherlands. This ethnographic research illustrates how perceptions and attitudes toward childbirth pain are affected by definitions of a "natural" birth, women's capacity to give birth, and the presence of professional and social support for non-medical births., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth., Design: ethnography., Setting: tertiary hospital in Australian city., Participants: sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork., Findings: women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence., Key Conclusions: informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices., Implications for Practice: as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: to explore the cultural, social and economic needs and challenges of women in northern Ghana as they resume their day-to-day lives post obstetric fistula repair., Design: a critical ethnographic approach., Setting: a state run fistula treatment center in Tamale, northern Ghana, and 24 rural communities in northern Ghana., Participants: ninety-nine (N=99) participants were recruited using purposive, convenience and snowball sampling. The sample consisted of women (N=41) who had experienced an obstetric fistula repair and their family members (N=24). Health care providers (N=17) and stakeholders (N=17) who had specialised knowledge about reintegration programs at a community or national level were also included., Findings: the needs and challenges of northern Ghanaian women post obstetric fistula repair were historically and culturally rooted. A woman's psychosocial acceptance back into her community post obstetric fistula was significant to her well-being but many women felt they had to 'prove' themselves worthy of acceptance and hid any signs of urinary incontinence post obstetric fistula repair. The cost of treatment compounded by a woman's inability to work while having the obstetric fistula exaggerated her economic needs. Skills training programs offered assistance but were often not suited to a woman's physical capability or geographic location. Many women who have experienced obstetric fistula along with women leaders have initiated obstetric fistula awareness campaigns in their communities with the aim of overcoming the challenges and improving the reintegration experiences of others who have had an obstetric fistula repair., Conclusion: developing understanding about the needs and challenges of women post obstetric fistula is an important step forward in creating social and political change in obstetric fistula care and reintegration., Implications for Practice: Strategies to support women reintegrating to their communities post obstetric fistula repair include exploring alternative forms of skills training and income generation activities, creating innovative pre and post obstetric fistula health education and community awareness to reduce the perception of the condition as 'incurable', and promoting peer advocacy., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: we explored how women in northern Ghana who have or have had obstetric fistula and those close to them perceive support., Design: focused ethnography, that includes in-depth interviews, participant observation, and scrutiny of relevant records., Setting: a fistula treatment centre in a regional urban centre and three remote villages located in northern Ghana., Participants: the sources of data included in-depth interview (n=14), non-participant observation and interaction, as well as scrutiny of relevant health records and documents. Participants for in-depth interviews and observation included women affected by obstetric fistula, their partners, parents, relatives, nurses and doctors., Findings: presentation of obstetric fistula information, particularly by Non-Governmental Organisations was not in a format that was readily understandable for many women and their families. Food and other basic requirements for daily living were not necessarily available in the fistula treatment centre. Travelling for care was costly and frequently not easily accessed from their communities. Fistula repair surgery was available at unpredictable times and only for a few days every one to two months., Conclusions: women perceived support from spouses/partner, family members, and other relatives but much of this is limited to tangible support. Perceptions of support were particularly focused on access to information and finances., Implications for Practice: the implementation of strategies to increase support for women living with obstetric fistula include improving access to fistula repair treatment, directing resources to create a dedicated specialist fistula centre located where most cases of OF occur and providing education to front-line workers. Strategies to prevent fistula as well as identify and support safe motherhood practices are needed for women affected by obstetric fistula., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

This paper suggests that the incorporation of a sociological perspective into transcultural nursing would enhance the present anthropological approach. The discussion considers the concept of ethnicity, which encompasses a wider perspective than that of culture alone, and is inclusive of both dominant and subordinate human social groupings. Anthropological understanding explores the beliefs and values of a particular community whereas sociological understanding reflects the position of that community within society and their associated experiences. The case is made by discussion of transcultural nursing, its roots in anthropology and the contribution that a sociological perspective can provide. Concepts of assimilation and acculturation are discussed, as is the adaptive nature of culture. A need for application of theoretical understanding to professional practice is demonstrated and a requirement for development of cultural competence is highlighted. The implications for curriculum development are discussed. This paper adopts a perspective that considers transcultural health care from the focal point of the user of health care service rather than the more usual dominant provider viewpoint.