Women's awareness of the role of midwifes and their preference for health professionals for maternity care:a systematic review

Malak Yousef Bughdadi,Afnan A.ALbokhary

1Faculty of Nursing,Department of Midwifery Practice,Umm Al-Qura University,Alabdeyah Makkah 24351,Saudi Arabia. 2Ministry Of Health,Kingdom of Saudi Arabia,Asshawqiya 8003,Makkah,Saudi Arabia.

Abstract Objective: Several studies have shown that women are more satisfied with midwife‐led care. However, their awareness regarding the midwives’ roles was inadequate. The effect of the women’s awareness on their preferences for maternity care from health professionals has not been understood. To identify research findings presenting women’s awareness of midwives’ roles and preferences for receiving maternity care from health professionals.Methods:The systematic literature review used various electronic search engines,including SCOPUS, PubMed, ScienceDirect, and Cochrane Library. Also, other grey literature sources,including Google Scholar,were utilized to identify articles.The search included only English language articles published between 2017–2021. Results: This search provided 20 studies that fulfil the inclusion criteria and are relevant to the Population, Intervention,Comparison, and Outcomes question. The knowledge of midwives’ role among the public is well studied in the literature, and few papers (4 studies) focused on women’s perceptions.The review of existing literature indicated the midwifery workforce in Arab countries like Saudi Arabia,the impact of midwives’role on maternal and child health outcomes,women’s experiences regarding midwife‐led care, women’s knowledge and perception regarding the role of the midwife in maternal care, and the womens’ preference for midwifes’ role within the range of maternal care professionals.Conclusion:The review found a lack of awareness and knowledge among the public about the midwife’s role, particularly among women.According to evidence, women’s preferences for choosing health professionals for maternity care primarily depend on being informed about their care, being given care options,and the health professionals’ comprehension of their particular care needs.

Keywords: Saudi Arabia; midwives; midwifery; maternal; maternity; child; midwives’ roles and competencies; midwife‐led care

Introduction

Midwives are multifaceted healthcare providers with a wide range of knowledge and skills, ranging from prenatal care to education and research [1]. The evidence indicates that high‐quality midwifery care is associated with significant and consistent decreases in maternal and newborn mortality [2]. In addition, midwives are essential in health counselling and education, not only for females but also for their families and communities [3, 4]. According to recent evidence,midwives, act as an influential and essential core member of the health workforce for sexual, reproductive, maternity, infant, and adolescent health. They have proven to be critical in achieving meaningful progress toward several of the 2030 agenda for Sustainable Development goals and targets [5]. However, the awareness regarding midwives’roles and competencies is limited. The lack of awareness can negatively affect perceptions and restrict access to high‐quality maternity care, particularly where midwifery care is introduced [6, 7]. Previous studies have shown that women’s preference for selecting health professionals for maternity care is based primarily on being informed about their care and provided care choices [8–10]. According to literature, the public’s knowledge regarding midwives’ roles and competencies has been poor,“especially among women” over the years worldwide, despite the growth of the midwifery workforce [7, 10–14]. There is significant evidence that women who received midwife‐led care throughout their pregnancy, delivery, and postpartum have better health outcomes[15]. Understanding the women’s perception and knowledge of the midwife’s role may influence access to maternity care. Therefore, a systematic review was undertaken to identify current literature to gain a deeper understanding of women’s awareness of midwives’ roles and their experiences with midwife‐led care on their preferences for receiving maternity care from health professionals. This review aims to identify research findings presenting women’s awareness of midwives’ roles and preferences for receiving maternity care from health professionals.

Population, Intervention, Comparison, and Outcomes question: Are women (P) aware of midwives’ roles and competencies in maternity care (I), and from which type of health professional do women prefer to receive maternity care(O)?

Research questions:Does midwife‐led care affect maternal and child health outcomes? Are women aware of midwives’ roles and competencies? From which type of health professional do women prefer to receive maternity care? Does women’s level of knowledge affect their preferences for health professionals?

Method

The literature review used different electronic search engines,including SCOPUS, PubMed, ScienceDirect, and Cochrane Library. In addition, various grey literature sources, including Google Scholar,were searched to capture all relevant information and additional records identified through other sources (snowballing). The search strategy used the following keywords and combinations to identify related articles: the initial search used for all databases included the following keywords and Boolean connectors: (“Women” or “Woman”or “Pregnant”) and (“Knowledge” or “Awareness” or “Perception” or“Views”) and (“Midwife” or “Midwives” or “midwife‐led care” or“Nurse‐midwife” or “Midwifery”) and (“Role” or “Competencies” or“Competency”). In addition, the truncated keyword ‘Midwife＊’ was added to focus on the midwives’ scan results. Finally, the search was refined to include only English‐language articles published between 2017 and 2021.

This search provided 18 studies from the PubMed database, 102 from SCOPUS, 109 from ScienceDirect, and (34 results) 4 Cochrane reviews and 30 trials from the Cochrane Library database; all studies were related to PICO question and limited to midwifery.

Results

The final result includes 20 studies that fulfilled the inclusion criteria and were relevant to the PICO question. The researcher relied on the research questions to include and exclude studies, and key search words and synonyms were created from the research question. The duplicates of studies, incomplete data for analysis, and studies that focus on other health professions and do not include midwives were excluded.

Figure 1 The PRISMA diagram describes the decision-making process we used during the overview.PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analysis.

Figure 1 shows the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis flow diagram used to report the studies’screening, and this diagram lists all choices made during the research selection process [16]. The literature in this review comes from different countries and presents a global view of the evidence.However, in this study, four themes were observed in the literature,i.e., the impact of midwives’ role on maternal and child health outcomes, women’s experiences regarding midwife‐led care, women’s knowledge and perception regarding the role of the midwife in maternal care and preference for midwifes’ role within the range of maternal care professionals. Table 1 presents the themes and related papers. Therefore, each study has been reviewed, as shown in the summary of studies in Supplementary Table S1.

Discussion

Women‐specific healthcare should effectively fulfil women’s requirements as they get older and transition through different stages of life [31]. In Saudi Arabia, women‐specific healthcare services are available either as standalone clinics or as part of more prominent hospitals and institutions [17]. In addition, women with uncomplicated pregnancies are provided at least eight visits throughout their pregnancy, beginning in the first trimester [32].However, low attendance is a serious concern , even though Saudi Arabia has a maternal mortality ratio of 17 per 100,000 births [32,33].

According to Alanazy & Brown (2020), the average percentage of women who do not attend their maternal care visits is 47.9% [32].The evidence indicated that the midwife’s role significantly influences maternal and child morbidity and mortality. A modelling study aggregated the findings from 88 countries using the Lives Saved Tool to estimate the number of preventable maternal and neonatal deaths and stillbirths by 2035. The study results estimated that relative universal coverage of midwife‐delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths,allowing 4.3 million lives to be saved annually by 2035[5].

In a scoping review conducted by Coates and Foureur (2019), their study’s outcomes demonstrated that midwives support women with mental health problems in addition to screening and recommending[17]. Furthermore, midwives provide mental health interventions(e.g.counselling)with positive outcomes for childbirth fear or helping women who experienced emotional trauma at birth [19]. Moreover,previous studies revealed that midwife‐led care improved empowerment and satisfaction in women during pregnancy,birth,and postpartum [23, 24]. In addition, midwives empower women by providing information, education, and guidance [25]. Counselling provided by midwives positively impacted the women’s birth experience; midwife‐led counselling increased women’s confidence in childbirth by providing them with information and knowledge and reducing their anxiety about childbirth[26,34].

According to recent evidence, many socio‐cultural and environmental factors affect midwife‐women relationships, including familial connections,culture and religion, various healthcare systems,official knowledge, and information sharing. In addition, family engagement in maternity care may impact midwife‐woman relationships, especially when midwives and family elders have differing pregnancy knowledge, producing stress throughout the women’s maternity care[28]. In the context of previous findings from Indonesia,a descriptive observational study was conducted to identify and compare factors that influenced women’s decision to seek maternity care from a midwife or a traditional birth attendant. The findings revealed that the women’s choice of maternal healthcare caregivers was influenced by the women’s education, individual needs, expectations and aspirations, usual source of healthcare payment, family encouragement, and traditional beliefs. In addition,the study found that women who sought maternity care from a midwife had higher satisfaction with traditional birth attendant [34].

In reviewing the literature, the key results that researchers agreed on were the public’s lack of awareness and knowledge about the midwife’s role, particularly among women. The literature demonstrated that the general public lacked knowledge about the role of midwives worldwide. McKellar et al. (2019), from Australia, found a lack of understanding among the public regarding midwives’ high skills and expertise[7].A qualitative exploratory research study found that pregnant women lacked knowledge of midwives’scope of practice and competencies in Germany.In addition, most women lacked access to standardized information about midwives’ scope of practice [14].Similar findings were reported in Thailand. The study’s results revealed that women were unaware of the midwife’s role and were not in contact with a midwife during their pregnancy. In addition, the above mentioned study reported that Thai women’s perceptions of the midwife’s role during labour included aspects such as providing support,encouraging pushing,and assessing health in the labour room rather than performing procedures [12]. In contrast to previous findings,in the United States,a quantitative cross‐sectional study used pre and post‐test design. Prior to the study’s intervention, most participants had sufficient knowledge about midwives’ roles in maternity care[10].Although knowledge and perception of midwives’roles may be limited in the literature, the lack of understanding can influence perceptions and impede access to high‐quality maternity care, especially in places where midwifery is introduced [10].

Regarding the women’s perceptions of midwives’ caring behaviours during labour, a Jordanian study revealed that women had negative experiences during childbirth, including dismissive manners and physical and empathic abandonment by midwives. Women expected midwives to pay attention to what they had to say, respect them, and be genuinely there for them when they needed them [29]. The evidence revealed that women at risk of preterm birth had a similar positive experience with midwifery care compared to women with uncomplicated pregnancies. In the United Kingdom, Turienzo and others (2021) conducted a study among 334 women that used exploratory sequential mixed method design [30]. The study’s goal was to investigate the care experiences of women with preterm birth risk factors participating in the Pilot Study of Midwifery Practice in Preterm Birth Including Women’s Experiences. The Pilot Study of Midwifery Practice in Preterm Birth Including Women’s Experiences group of mothers in the study had more favourable attachment experiences with their newborns and had better physical health postpartum. In addition, women at higher risk of PreTerm Birth who received midwifery continuity of care were more expected to report higher levels of trust,safety,and care quality.Midwife‐led care is upto come extent equally as safe and effective as obstetrician‐led care and delivers optimal birth outcomes in low‐risk women [2]. However,women’s preferences for choosing health professionals for maternity care have been proven primarily dependent on being informed about their care options and comprehension of their care needs[8,10].In an earlier systematic review study, the obtained results demonstrated that the critical components of the continuity of quality midwifery care that women appreciated were; the midwife–woman relationship,personalized care, the building of trust, and empowerment [35]. The previously mentioned Thai study by Liblub (2020) reported that most pregnant women recognized the physician as essential for conducting normal births [12]. During labour and birth, women preferred to receive care from the physician over the midwife because women felt more confident with the physician.In addition,women believed that a doctor was qualified to perform a vaginal delivery and a variety ofother midwifery tasks during labour and delivery [12]. However,another study found that selecting a midwife as a pregnancy care provider was linked to increased awareness of the role of a midwife among women [11].

Table 1 Themes and related papers

Implications for practice

This has implications for practice and the evolution of maternity services. Women’s understanding of midwives’ roles is essential for care continuity. Therefore, midwifery services and maternity care professionals should prioritize educating women about midwives’competencies in maternity care. Organizations and maternity service providers should understand the value of developing a relationship between women’s awareness and continuity of midwife care and offering the resources and circumstances to make it possible. To recognize the factors that influence women receiving maternity care from health professionals, it is essential to address the relevant issues,clarify the women's knowledge and preferences of maternal care, and provide the potential strategies used in the literature.

Limitation

Currently, with the growth of the midwifery workforce globally, there is still a lack of understanding regarding the full scope and role of a midwife. This possible lack of knowledge may have hindered the adoption of midwifery care models by restricting certain women’s ability to make informed choices about their care options. However,the current understanding and knowledge of midwives’ role and competence among women have not been adequately investigated in Arab countries, particularly in Saudi Arabia. Thus, there is a need to appreciate the women’s knowledge of the midwife’s role, which may result in more satisfying birth experiences and positive health outcomes. Therefore, this review may give the policymakers a basic idea about the women’s understanding of midwife competencies,which may influence access to maternity care to enhance more satisfying birth experiences and health outcomes.

Conclusion

The literature shows that the global health sector is continuously progressing and so does the growing needs of the maternal population.Especially in Arab countries,the Saudi health sector is developing;it is experiencing challenges as the population grows, residents’requirements are evolving, and the low attendance of women in maternal care is a serious concern. However, researchers agreed on the key results of the women’s lack of awareness and knowledge about the midwife’s role. The lack of awareness can negatively affect perceptions and restrict access to high‐quality maternity care,particularly where midwifery care is introduced. According to evidence, the women’s preferences for choosing health professionals for maternity care have been proven to be primarily dependent on being informed about their care, being given care options, and the health professionals' comprehension of their particular care needs.