Our understanding of physiological birth may appear to us to be straightforward. In this article, based on her PhD studies at City, University of London, Florence Darling, QMNC Research Fellow, discusses how complex a physiological care approach is, and emphasises the need for research to understand its use in practice, and related competence.
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The complexity of a physiological care approach: researching use and competence
Introduction
The persisting problem of increasing and wide variations in routine clinical intervention use in childbirth is cause for global concern. In this article, I call for a greater understanding of the complexity of a physiological care approach, and focused research on use of and competence in related care practices, forming an important part of our work to address the problem of routine clinical intervention use.
The article begins with a brief description of the problem of clinical intervention use in childbirth and of the landscape of midwifery research to understand routine clinical intervention use. I will then discuss the complexity of a physiological care approach, the importance of research to understand its use, and midwives’ competence in its use.
Clinical intervention use and midwifery research
The discussion here centres on the problem of routine clinical intervention use but it is important to reiterate that childbirth is faced with the dual problems of underuse and routine or overuse of clinical interventions. For example, caesarean (CS) rates are 7.4% in Sub-Saharan Africa but 63.4% in East Asia . Both problems cause harm and require urgent action. A range of clinical and non-clinical interventions are recommended and targeted to effect change at systems, organisations, professional and individual levels but the problem of underuse and routine use including wide variations persists .
Much of midwifery research on understanding the problem of routine clinical intervention focuses on exploring the experiences of midwives’ responsible for using a physiological care approach and providing this care in different birth settings. In a physiological care approach, a watchful attendance is advocated. Care is responsive to the woman’s physical and emotional needs. Clinical interventions are used only when problems that may arise in the woman and her baby warrant its use, thereby reducing routine practise. Physiological care practices that may be used in this context range from ensuring that the woman: labours in a calm and undisturbed environment with birth companions of her choice; has her comfort needs met; is able to eat and drink; is able to move freely and, if she wishes, is able to adopt upright positions; and has access to a range of pain relief options while the midwife provides constant encouraging and supporting companionship. To a lesser extent these studies have also explored the experiences of obstetricians and women.
A recent review of these studies showed that most explored facilitators and barriers to implementing a physiological care approach at a professional group level. Findings in these studies are mainly derived from interviews, and the study of facilitators and barriers at an organisational and individual levels are lacking. These present much needed areas for research . However, an equally urgent gap identified in the literature is a lack of research on comprehensive measures or assessments of the use of and competence in physiological care practices, to understand why clinical intervention use may vary. This represents an important area of work in, for example in implementation research, and is driven by the understanding of complexity which is described as arising from the intervention used i.e. a physiological care approach; and contextual factors that can act as facilitators and barriers to its implementation. While study of both is equally important, the focus of discussions below is on the complexity of the intervention (a physiological care approach) in calling for research to understand use and competence.
The complexity of a physiological care approach
While the physiological care approach advocates a ‘watchfulness’ and as such is not regarded as an intervention in the traditional sense of ‘acting to become intentionally involved in a difficult situation, in order to improve it or
prevent it from getting worse’ (Cambridge dictionary, 2023); it is conceptualised as an intervention because its ‘watching’ is not without intent. The watchfulness involves ‘waiting’ on the physiological functioning of labour; and this time is used as both a diagnostic and a therapeutic tool to see ‘what nature does’ .
Complexity in this context arises for a number of reasons. Firstly, it arises from a care approach rooted in labour, which is a complex and individualised process. Labour progress can vary considerably from woman to woman and throughout labour . The physiological care approach acknowledges the non-linearity of labour progress when standardised time frames to assess and actively manage progress are avoided. Instead, care in this approach is individualised to each woman’s progress and assessment of her need. In contrast, in current systems of care informed by an interventionist care approach, labour is actively managed and standardised to the care of all women. In the interventionist approach, labour progress is classified into different stages and the length of labour progress is pre-defined in each stage. This facilitates diagnoses of ‘normality or abnormality’ for each stage, and clinical interventions are used to manage ‘abnormalities’ that occur (McCourt and Dykes, 2010). In this context, care is focused on exerting greater control over a complex and unpredictable labour process using routine clinical interventions.
Secondly the physiological approach is not about avoiding clinical interventions altogether. Care is a complex balancing act of providing the right care at the right time, knowing when to wait and when to intervene. However, noting this complexity, de Jonge et al (2021) state that it is much more difficult to ‘watch’ and then act at the right time (attend/respond), even when based on evidence, than it is to routinely execute a protocol.
Thirdly, complexity arises from women’s preferences for care in labour and birth. These preferences have their roots in myriad influences arising from women’s personal views, the media, friends and family and societal culture around birth. Women and midwives can pool their knowledge and resources to use and experience a physiological care approach. Equally midwives and obstetricians may have little control over contextual and individual level factors that influence women’s decision-making that may lead to preferences that differ from what may be recommended, be it a physiological or an interventionist approach (Darling et al., 2023). Either way, it is important that women feel listened to and respected.
The complexities outlined attests to the challenges posed when measuring or assessing use and competence. Unlike a tick box or checklist of interventions that must be adhered to (more widely examined in implementation research), in labour, care practices are highly individualised. A single physiological care practice may be used several times at different points, or several may be used at a single point. Care practices in this context may be described as being ‘used’ rather than ‘adhered to’. Further the use of a particular physiological care practice may not occur because clinical assessments demonstrate a need for clinical intervention, or because the woman prefers a different approach from the physiological care practice prescribed (Darling et al., 2023). Conversely, a physiological care practice may replace clinical intervention, even when indicated, because of the mother’s strong preference. As such a high level of competence is needed and such assessments can rate the appropriate use of physiological care practices; whether the woman’s needs and her preferences were met; confidence to challenge routine clinical intervention use; and if appropriate make timely referrals when problems arise (Darling et al., 2023).
Underpinning research in childbirth with an understanding of this complexity could lead to us to ask better questions to seek solutions. Research drawing on, for example, the principles and theories in implementation science could support this work.
Conclusion
We need a greater understanding of the complexity inherent in a physiological care approach to drive research on its use and competence amongst health care professionals. This will need midwives and other birth professionals to progress work to aid this learning and understanding amongst women, healthcare organisations and care professionals.
The research will also need the development of indicators and validated tools to measure or assess care across the labour continuum and identified by the Quality Maternity and Newborn Research Alliance as one of its research priorities. This is an important step to support research exploring use and competence in a physiological care approach in efforts to progress its implementation; reducing routine clinical intervention use and variations in its use..
References:
Darling, F; McCourt, C., Cartwright, M ( 2023) ‘Facilitators and barriers influencing the implementation of a physiological care approach during labour and birth: a mixed methods study in two obstetric units (Unpublished thesis)
de Jonge A, Dahlen H, Downe S (2021) ‘Watchful attendance’ during labour and birth. Sex Repro’d Healthc, doi: 10.1016/j.srhc.2021.100617. Epub 2021 Mar 19. PMID: 33774268.
McCourt, C and Dykes, F. (2010) ‘From Tradition to Modernity: Time and Childbirth in Historical Perspective,” In McCourt, C (Ed), Childbirth, Midwifery and Concepts of Time. UK: Berghahn Books. pp.17-36.
Quality and Maternal and Newborn Research Alliance (2014). Available at https://www.qmnc.org/
Florence Darling
BSc Midwifery (First) ; MSc in Public Health; MSc in Clinical Research Methods.
QMNC Research Fellow [email protected]
October 2023