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Background: Breastfeeding is crucial in providing optimum nutrition and health for babies' to develop into healthy adults and has important emotional, physical and psychological benefits on maternal health. The UK has stubbornly low breastfeeding initiation and continuation rates. To address this, the government has policies targeting maternity and public health services. Furthermore, UNICEF UK introduced Baby Friendly Initiative (BFI) Hospital Standards in 1998 and Midwifery Education Standards in 2002. The University of Nottingham adopted BFI Education Standards in 2005 and have maintained accreditation since 2008. The BFI curriculum changes incorporated a knowledge, skills and attitude framework for teaching, learning and assessing. The embedding of positive attitudinal and skills facilitation of breastfeeding within the curriculum changes was essential. The influence of Trust's organisational culture on student learning was considered critical due to its impact on midwives working practises and pre-registration midwifery curricula having a minimum of 50% clinical practice. There is a lack of information about the efficacy of BFI Education Standards on student learning and application to practice. The aim of this study was to explore factors affecting student midwives competence and confidence when incorporating BFI Education Standards into clinical practice. Methodology and methods: A three year longitudinal multiple educational case study of a Bachelor of Midwifery programme commenced in 2009. Ethical and R&D approval were gained from the University and five Trusts, each at different stages of BFI clinical accreditation. The inclusion criteria were any student in the September 2009 midwifery cohort and their allocated midwife mentors. From a cohort of 32 students, 22 consented and 16 supplied data at each collection point throughout the three years. Students identified 92 midwife mentors, they had worked with, who were then invited to participate; 16 consented and 6 supplied data at each collection point throughout the three years. A total of 92 questionnaires and 70 one hour interviews were conducted. Data collected from students included questionnaire, individual interview and documentary evidence at 6, 18 and 30 months into the programme. Data from midwife mentors was questionnaire and individual interview at each stage. Documentary evidence was obtained from the students' NMC record of clinical skills and second year biology examination question on infant feeding. Data analysis used NVivo for qualitative data management, and PAWS for quantitative data analysis. Verbatim transcription of interviews was followed by thematic analysis. Findings: Findings are presented using BFI 'Ten Steps' Standards with the underpinning knowledge, skills and attitude framework. All students considered themselves to be competent and confident in 'normal' aspects of infant feeding but only competent in 'complex' feeding scenarios. Students self reported the theoretical component was most important to their learning in years 1 and 3 and clinical placements in year 2. Students who were mothers and students working in BFI accredited units had better examination results. Changes in workforce skill mix and reduced community midwife visits were factors in reported gaps of 'complex' breastfeeding learning opportunities. These were addressed by scenario role play. Reductions in Infant Feeding Advisor hours were found to correlate with increased formula supplementation. Mentors praised students' enhanced theoretical knowledge from their first year, and assessment and planning in the third year. They attributed this to the BFI curriculum. More prescriptive and structured organisational documentation facilitated student learning. Theory practice gaps existed at all five case study sites. At BFI accredited sites mothers and babies were statistically more likely to experience skin-to-skin following any mode of birth (n=1462 p<0.001 phi=0.21). At all sites a normal birth statistically increased the opportunity of mother-baby skin-to-skin (n=1462 p<0.001 phi=0.57) and initiation of breastfeeding (n=1462 p<0.001 phi=0.52). Students embraced a 'hands-off' technique to support breastfeeding and hand expression of the breast against prevailing clinical role modelling. Techniques students developed were 'shadowing', use of props, use of feeding cues and increasing the accessibility of their knowledge to women through facilitative communication skills. Use of infant feeding tools provided through the curriculum supported student learning. Detail provided within the postnatal data was poor and mirrored by mentors reporting poor use of relevant organisational documentation. Students had little opportunity to develop constructive formula feeding support, sterilisation of feeding equipment and reconstitution of formula milk. Anxiety was expressed by mentors and students in providing support to formula feeding women within a BFI framework. The use of interactive teaching methods and individual assessment through a workshop in year 3 were identified by students as significant to their learning. Students desire to support women to breastfeed grew over the 3 years. This was independent of personal feeding experiences of students who were mothers and the non-mothers embedded norms. The reinforcement and incremental delivery of the BFI curriculum in each year was identified as essential in this process. Conclusion: A BFI accredited midwifery curriculum positively impacts on student learning in infant feeding, raises the profile of infant feeding within postnatal care and enables students to create positive experiences for women. This study's findings would recommend that all midwifery curricula embrace BFI Education Standards within a knowledge, skills and attitudes framework.

Consultant nurse and midwife roles, with the expectations of significantly moving forward the professions in relation to practice development, effective leadership and quality care provision, have been a major UK policy initiative since 2000. Whilst consultant nurses have received much attention, consultant midwives have been relatively little researched. This study aimed to explore the intricacies of the consultant midwife role. Using an in-depth qualitative case study design, the roles of eight consultant midwives across eight NHS Trusts in England were studied. Data were collected via in-depth interviews with consultant midwives, their heads of maternity services and consultant obstetricians; additionally, the consultant midwives were observed in practice and documentary evidence (their job descriptions) were examined. Data were analysed thematically and aggregated, revealing three dominant themes related to clinical wisdom, taking control and shaping the future. Findings showed that the consultant midwife is in a position of power, built on a foundation of clinically acquired wisdom, transformational leadership skills and a belief in woman centred care, essential to a profession fit for the future. Individually and collectively, the consultant midwives conveyed a passion for their role, whilst aware of the demands of their position. Their impact lay in relation to the way they used their experience, skills and understanding, to undertake complex roles in practice, juggling responsibilities to effect change and improve services for childbearing women and their families. Their strength was born out of acquired knowledge and expertise, as leaders and as role models, influencing not only practice but the midwives of the future. This thesis provides the first in-depth exploration of the consultant midwife role and as such greatly strengthens the hitherto limited evidence base. As well as focusing on the particular aspects of day-to-day consultant midwifery it also gives detailed recommendations for further development of the role organisationally.

After completing a three year midwifery degree course at university newly qualified midwives are expected to function fully as autonomous and accountable practitioners. This interpretive phenomenological investigation explored the lived experiences of twelve participants throughout their first twelve months post registration. Data were collected using semi-structured interviews at three points in time: the point of registration, four and twelve months post registration. Analysis and interpretation of these data were achieved using van Manen's methodological structure combined with an interpretive phenomenological approach. The findings revealed two final interpretive themes that described the meaning of 'becoming a midwife'. These were 'Fairy tale midwifery: fact or fiction' and 'Submissive empowerment: between a rock and a hard place'. The first incorporated the two super-ordinate themes false promises and reality shock; the second incorporated four super-ordinate themes beyond competence, part of the club, self doubt and struggling. This study has contributed to existing knowledge by way of highlighting the 'crisis of reality shock' that these newly qualified midwives experience surrounding the change of responsibility upon qualification. When participants experience the 'real' world as a newly qualified midwife, they may have to undertake work that previously they did not want to do and could opt out of as a student. The newly qualified midwives did not perceive themselves to have autonomy and by virtue, responsibility. Lack of autonomy and the ability to undertake decisions can lead to high levels of anxiety in the newly qualified midwife. Despite this, they prefer to work on the delivery suite where they have instant access to support and advice compared to being on their own in what they perceive to be a chaotic community setting. It may be that transition is an emotional challenge and like birth, the reality is that preparation might help, but that the 'reality' can only be experienced.

This multi-case study explores the transition experience of graduate midwives during the first months of registered practice. These midwives had experienced a curriculum designed to produce midwives fit for practice at the point of registration but also equipped with the capability for self- directed personal development. Dramaturgical analysis of data collected from on line blog and telephone interviews explores the midwives' significant learning experiences to consider how their individual dispositions impact on their learning practices, and further analysis for workplace affordances clarifies how the ongoing development of these new midwives is affected by the community, structures and artefacts of the workplace. Findings suggest that the affordances of the workplace in terms of the activities available to these new midwives support a high quality learning experience, which promotes their rapid development as fit for purpose autonomous practitioners. The interdependencies of the workplace are structured to maintain the status quo rather than support change and development. Issues identified as conflicting with personal development are lack of time or resources to perform to their full potential, opposition from more established members of staff to their initiatives, and a culture of medicalisation which undermines a model of woman centred care and the promotion of normal childbirth. High academic achievers continue to make use of academic practices and tools to support learning and critique of practice but all learn mainly through experience and consulting others. The study concludes by recommending areas for further study. These relate to evaluating different models of preceptorship, exploring the dissonance between learning cultures in the university and practice setting and exploring the dissonance between ideals of midwifery practice and current structures of maternity care.

This thesis presents a case-study of interprofessional working in one English NHS maternity unit. Problematic interprofessional working in UK maternity care can contribute to poor outcomes for women using the services, as well as to difficulties for midwives. Relevant research to date has focused mainly on midwife-doctor relationships. Associated social factors, namely, issues of gender, power, professionalism and the medicalisation of birth, have been identified over the last two decades; however, there have been only sporadic improvements in this area. There has been no in-depth study of how micro-level discursive mechanisms affect midwives" interprofessional relationships. The aim of this study was to explore how midwives" discursive practices relate to the social factors listed above. Critical Discourse Analysis (CDA) was applied to 17 midwife-authored research papers and four documents governing midwifery practice. Semi-structured interviews were conducted with 19 midwives, and 100 hours" observational data were collected over a period of one year. A sampling strategy of maximum variation resulted in the recruitment of interview participants of differing seniority, practice locale (hospital/community) and involvement in role extension. Additional interviews were conducted with four obstetricians and seven service-users. Interview and observational data were analysed following both thematic and CDA principles, in order to aid identification and examination of pertinent discursive practices. Out of 17 relevant social practices identified, 13 involved midwives" discursive practices which reinforced traditional notions of professionalism, gender and the medicalisation of birth. However, most midwives in the unit expressed satisfaction with their interprofessional relationships; this appeared to hinge on the fact that their interaction with the obstetricians in the unit were grounded in the shared exercise of power. Midwives" relationships with some other occupational groups were more problematic, particularly where they had similar status in the occupational hierarchy. A key finding was that good interprofessional relationships between midwives and other staff did not necessarily enhance women"s experiences of maternity care. The thesis contributes to the knowledge base about interprofessional working among midwives by developing a theoretical approach concerning the relationship between communication and the operation of power in their working environments. It has also produced findings about midwives" relationships with both medical and non-medical colleagues. Implications are discussed concerning midwifery, women using the maternity services, and our society"s approach to birth.