Exploring the use of health technology in community-based midwifery care – an interview study | BMC Pregnancy and Childbirth

This study uses a qualitative approach to understand the lived experiences of community midwives in the UK regarding health technologies. By emphasizing individual experience, this orientation aims to provide authentic insight into the equipment challenges midwives face [6]. Qualitative research captures and explores people’s experiences and perceptions [6]. Therefore, qualitative semi-structured interviews were used to explore midwives’ knowledge, experiences, and perceptions of health technologies used in community maternity care. This method allows researchers to cover issues of interest to them but also allows the participants to voice issues of personal and professional significance and importance [7].

Sampling and recruitment

Midwives with current or previous experience working in community-based settings within the UK were invited to participate in this study. The study was promoted on social media (on Facebook groups such as ‘Maternity and Midwifery Forum’ and ‘Continuity Matters’ and ‘Midwifery Study Days & Conferences’ and on Twitter) with posts linking to the study webpage. This webpage included the Patient Information Leaflet (PIL) and contact details for the study team for those interested in taking part. All those who responded and met the inclusion criteria were invited to participate in the interview. The decision to stop interviewing was discussed and agreed upon among the members of the research team when sufficient information had emerged, and there was a satisfactory explanation of the emerging themes.

Interviews

Qualitative semi-structured individual interviews lasting approximately 30 min were conducted by telephone. The interviews were all performed by the primary researcher, HE, apart from one, done by JM. Informed verbal consent was obtained prior to the interview. A topic guide was used. The topics were based on the available literature and drew on issues from topic guides for other studies that have investigated clinicians’ views of POCTs [8, 9]. When developing the topic guide for a midwifery audience, informal feedback was obtained from community midwives. The guide was amended and added to as the interviews progressed.

The interviews were recorded using a digital audio recorder and transcribed verbatim by a professional transcriber. The primary researcher made field notes during and after the interviews.

Analysis

The transcripts were checked for accuracy and anonymised before being uploaded to a specialist software programme to assist in the organization and analysis of data (NVivo V.1). Thematic analysis of all the interviews was performed using a grounded-theory approach [10]. Grounded Theory is a qualitative methodology which guides systematic data collection and data analysis. This approach enables iterative generation of information which is grounded in the data through constant comparison. It is a particularly useful approach when exploring new or under-researched topics. Codes were used to group the data. Categories were created by grouping and comparing the codes. Single-sheet brainstorming supported the development of broad themes [11]. Transparency and dependability were ensured by creating an audit trail from the raw data to the themes and seeking the agreement of the analysis from the research team [12].

Researcher characteristics and reflexivity

The primary researcher was HE (MSc, female), a practicing community midwife and early career researcher. JM (BA (Hons), female) is a Senior Research Midwife with experience in qualitative research. MG (PhD, female) is a senior qualitative researcher. MG supported HE throughout the data collection and analysis process, including providing interview training. The midwives interviewed were given no information about HE or JM, apart from their current job titles. One of the midwives interviewed was known to HE, as they worked at the same NHS Trust but on different teams. Prior to the interviews, the participants were in contact with HE minimally, only to schedule their interviews. Having midwife interviewers allowed for flowing conversation. At times, interviewees asked HE about her own experiences. When this happened, HE explained that these could be shared and discussed once the interview was completed.

Findings

Thirteen interviews were conducted between October 2021 and March 2022. A further two midwives contacted the research team regarding participation. One was unable to be interviewed due to unavailability and the other did not meet the eligibility criteria.

Participant characteristics

All of the participants were midwives who were working in community settings within the National Health Service (NHS) or who had done so in the 12 months preceding the interview (Table 1).

Health technology used by the midwives interviewed

The midwives described using health technology for a range of tasks, including assisting in clinical decision-making, supporting public health initiatives, and providing reassurance. The health technologies used in a community setting by at least one of the midwives interviewed in this study are shown in Table 2. There are currently very few in vitro Diagnostic (IVD) POCTs (equipment that quickly analyses samples taken from the human body – immediately, on-site) used in community midwifery practice. The midwives interviewed did collect samples but would then send them to a hospital laboratory for analysis. Similarly, ultrasound scanning in the midwives’ NHS Trusts was performed exclusively within a hospital, and not by community midwives.

Themes and subthemes

The main themes and subthemes identified by the research team were as follows:

1)

Problems with current equipment.

a)

Issues in the context of remote working.

b)

Concerns regarding accuracy.

c)

Midwives’ perceptions of service user experiences.

2)

Equipment challenges working within the NHS.

a)

Lack of availability of appropriate equipment.

b)

Lacking autonomy in how to utilize equipment.

3)

Areas of unmet needs.

Theme one: 1) problems with current equipment

The midwives interviewed were generally satisfied with the health technology and equipment available to them. However, several recurrent issues emerged. Notably, despite describing serious challenges, midwives often framed these issues as mere inconveniences—suggesting a level of normalisation and acceptance of suboptimal conditions as an inherent part of their role.

1a. Issues in the context of remote working

Most of the midwives interviewed worked from a central base, such as a midwifery led unit, but would deliver much of their care in women’s homes or from GP surgeries and community spaces. They transported necessary equipment in their cars, and so wanted items to be portable and sturdy. Many of the midwives highlighted handheld fetal doppler devices as being too fragile. Several described doing ‘DIY repairs’ while waiting for a new device.

Almost all the midwives interviewed reported issues with thermometers, including axillary, tympanic, and single-use models. The accuracy was felt to be unreliable, and there were concerns that this was exacerbated when they had to store their equipment in imperfect conditions, for example, in their cars.

Many midwives also felt that the equipment provided to them was heavy or bulky, which they found impractical or potentially dangerous. Baby weighing scales, with a tray for the baby, were highlighted as a particular example. Some midwives interviewed used hanging scales, which they preferred, but most of those interviewed were not given this option.

1b. Concerns regarding accuracy

Several midwives had experiences with packs of urinalysis sticks that they thought were faulty or had degraded (for example, if the lid was left off). One midwife felt that the test took too long and suggested that this probably resulted in some underdiagnosis.

Many of the midwives discussed POCTs for diagnosing pre-labor rupture of membranes. The tests, which come in various forms, including swab tests and sanitary pads, detect amniotic fluid. These were not used by all the midwives and several reported that these were introduced and then withdrawn due to concerns regarding accuracy (and in one case, cost). The midwives generally felt that these would be useful, so long as the result could be trusted.

1c. Midwives’ perceptions of service user experiences

The midwives were sensitive to the experiences of women in their care, particularly because pregnancy and birth are times of increased physical demand and psychological vulnerability. They felt that some of their equipment had not been designed with this in mind.

Some midwives interviewed shared an awareness that the equipment they used could contribute to patients’ negative feelings about increased BMI and were keen to avoid this.

One of the midwives, who cared for a high number of non-English speaking women, felt that their carbon monoxide (CO) monitor was confusing to her patients, as the instructions for using it were complicated to explain, even with an interpreter. This monitoring is used to assess a woman’s CO exposure, and is intended to support referrals to smoking cessation services and provide motivation to those already quitting smoking.

Theme two: equipment challenges working within the NHS2a. Lack of availability of appropriate equipment

All the participants reported having little or no involvement in any of the purchasing decisions for equipment; the introduction of new health technologies; or their Trust operating procedures and policies regarding the use of equipment, such as referral pathways. There was a consensus that many of the issues with current equipment were caused by Trusts generally opting for lower priced options, with little consideration given to the staff using it.

Many of the midwives interviewed reported buying their own equipment, because they were not provided with something they felt they needed or because they felt that the items in their kit did not meet an acceptable standard. Examples included ophthalmoscopes, stethoscopes, thermometers, and oxygen saturation monitors.

Several reported frustrations at having to share equipment with colleagues, such as baby weighing scales and blood pressure cuffs, despite the equipment being required frequently.

The midwives all used aneroid devices, not digital devices, for blood pressure monitoring. Some were interested in using digital monitors, but these were either not available or the midwives had been dissuaded by concerns regarding their accuracy. Some of the midwives felt that aneroid devices were quicker to use, whereas others felt that access to a digital device would free up time to complete another task.

Two devices that many of the midwives were expected to use often, but that were not readily available, were transcutaneous bilirubinometers (TCBs) (used to monitor newborn jaundice) and oxygen saturation monitors for babies (used during routine and emergency assessments for respiratory or cardiac complications). The midwives were sensitive to the fact that these items are expensive, but still found it challenging not to have easy access to them. They described considerable time spent traveling, collecting and returning the devices between appointments. Donations from charities were sometimes used to pay for equipment that NHS Trusts were unable or unwilling to supply.

2b. Lacking autonomy in how to utilise equipment

On the whole, the midwives felt that all of the tests they were expected to perform were appropriate and beneficial to the care they provided. One exception to this was CO monitoring. At the time of the interviews, and still now, Trusts were instructed to share compliance data as part of the Maternity Incentive Scheme [13]. While the majority of those interviewed were in favour of the availability of this test to support smoking cessation, several wanted autonomy to use their equipment as they saw fit, as opposed to following a prescriptive, target-driven approach.

Theme three: areas of unmet needs

When questioned about areas of unmet needs, many of the midwives were hesitant about the idea of adding new tests, as they felt that this might overcomplicate care or deskill them, or the students they supported in practice. They were also concerned about the cost implications for their Trusts.

Several midwives expressed unease regarding introduction of equipment into the community that they were used to seeing in the hospital. While some felt that this approach would be beneficial, there was uncertainty about how it would work logistically, for example, how they would be trained and which pregnancy complications they could diagnose and manage without input from an obstetrician.

Generally, when participants reported wanting more health technology, they described devices that they knew were already on the market and that were often already being used by community midwives in other Trusts (including those interviewed for this study). These included transcutaneous bilirubinometers, serum bilirubin measurement equipment, oxygen saturation monitors (adult and newborn), tests for amniotic fluid, and CTGs. There were two POCTs not currently being used by any of those interviewed which the midwives felt would be useful and practical to introduce to a community setting. These were portable ultrasound scanners for presentation scans and IVD POCTs for diagnosing anemia, preeclampsia, and infections such as Group B Streptococcus (GBS) and UTIs.

There were four main reasons the midwives gave with regard to why they might like to see new technologies introduced:

1) To support decision making. Some midwives felt that their assessments lacked the same components and, therefore, the completeness of a hospital assessment. Where relevant portable technology existed, they felt should be incorporated.

2) To reduce the number of hospital visits for patients. This was important to the midwives as they felt that women often struggled with getting to the hospital or would prefer to avoid the hospital for psychological reasons.

3) To improve workload. For example, not having to spend time (often outside of normal working hours) transporting samples to a hospital or waiting for results to arrange appropriate treatment. Additionally, the workload of hospital colleagues could be reduced.

4)

To reduce the overmedicalisation of care. The midwives felt that once in the hospital setting, women referred for one concern might inadvertently be screened for other potential risks, which might heighten anxieties around birth and lead to a cascade of interventions.