Interprofessional cooperation by midwives in the field of out-of-hospital obstetrical care: an integrative review / Interprofessionelle Kooperation von Hebammen im Handlungsfeld der ambulanten geburtshilflichen Versorgung: ein integratives Review

In a first selection process, the titles and abstracts of the hits identified were checked with regard to their relevance to the research issues. The appraisal was conducted according to the predefined inclusion and exclusion criteria. Articles were only included if an abstract was available and if they had been peer-reviewed. The studies included were published in either English or German. In order to get a comprehensive overview of the literature published on the topic in question, qualitative and quantitative research reports, mixed-methods studies, and literature reviews were taken into consideration. To qualify for further scrutiny, studies needed to be carried out exclusively in the Western industrialised countries or in comparable societies, since it must be assumed that the health care system has an influence on the form of cooperation and that the challenges of cooperation are characterised by the respective social and healthcare systems. Publications included focus explicitly on the setting of cooperation in out-of-hospital obstetrical care or are transferrable to this context. A recent systematic review discovered that the interprofessional cooperation of midwives with other associated health professionals has as yet not been the subject of much research (Supper et al., 2015). Thus, the search was set up in a way to include studies investigating questions of cooperation across different disciplines, from which the specific perspective of midwives could be extracted. We excluded abstracts written for congress papers, comments on articles, editorials, book reviews, and policy documents. Furthermore, articles focussing on interdisciplinary learning, tertiary education, and further education, and thus directed at gaining interdisciplinary competences were excluded. Scientific papers that could be considered as irrelevant with regard to the issues concerned, such as studies on themes from other special fields, were also omitted from our research. Publications where a screening of titles and abstracts did not provide definite information were included in the full-text analysis. Any potentially relevant papers, the full text of which was not available online, were ordered via inter-library loan. After examination of the titles and abstracts, a total of 53 studies remained, which were then checked for suitability through a full-text screening.

Following the full-text screening, 28 studies were removed. Twelve studies had to be excluded because the midwives’ perspective was not represented. This perspective was either not the topic under investigation or it was not focussed on in the results presented. In one discursive paper, studies with and without consideration of the midwives’ perspective were included, which led to the exclusion of the article. However, one of the studies included met the inclusion criteria and had been incorporated in the results previously (Homer et al., 2009). Seven studies were found to have irrelevant topics and were, therefore, excluded. Four studies were concerned with conceptual delineations and had to be excluded. Two studies investigated cooperation in a hospital-based context, and their results could not be transferred to the out-of-hospital obstetrical care by midwives. Two potentially relevant reviews were excluded because, although they focussed on midwives, they were not performed within the research time frame or they referred to themes that complied with the exclusion criteria. A further publication was excluded because it was not based on empirical research. After completing this last screening, 25 of the 53 originally identified studies were included for further analysis. Table 1 shows an overview of the excluded studies.

The integrative review is based on a total of 25 studies, published between 2005 and 2015, of which 18 appeared in 2010 or later. Of the total of 25 studies, 5 each came from Australia, the United Kingdom, and Canada, 4 studies were from Sweden, 2 each from Germany and the Netherlands, 1 from Norway, and 1 from New Zealand. A comparison of the study designs shows that a qualitative research approach predominated in 13 studies, 10 studies employed a quantitative design, and 2 used a mixed-methods design.

Midwives participated exclusively in five of the studies (Ayerle et al., 2014; Fontein-Kuipers, Budé, Ausems, Vries, & Nieuwenhuijze, 2014; Murray-Davis, Marshall, & Gordon, 2011; Nagel-Brotzler et al., 2005; Skinner & Foureur, 2010), of which one had a qualitative design (Murray-Davis et al., 2011). The populations of all the other studies were of varying composition, consisting midwives, nurses, physicians, associated health professionals, addressees of the care system, professional groups from social services, representatives of administration and politics, as well as members of other professions. Midwives and nurses working mainly in the fields of child health care and child and family health care, either as public health nurses or as representatives of nurses’ associations, form the largest group of study participants, followed by physicians, usually general practitioners and obstetricians, and representatives of their associations. Professional groups from social services and addressees of the care system were less frequently represented than professional groups from the public health sector.

Many studies underline the benefits gained by cross-professional cooperation in health and social services (Ayerle et al., 2014; Barimani & Hylander, 2008; Barimani & Hylander, 2012; Clancy et al., 2013; Munro et al., 2013; Peterson et al., 2007; Psaila, Fowler et al., 2014). This is particularly the case in the care of women and families with special needs (Ayerle et al., 2014; Barimani & Hylander, 2008; Psaila, Kruske et al., 2014). Meetings between members of the various professions, where problems are jointly discussed (Psaila, Kruske et al., 2014), allow the psychosocial needs of families to be considered from all angles (Schmied et al., 2015). Furthermore, interdisciplinary case study conferences offer a chance to achieve competence in assessing families in problematic situations (Ayerle et al., 2014). Collaboration establishes contacts with women and families with limited access to professionals and services, which also enables a relationship to the families to be built up (Psaila, Fowler et al., 2014).

Barimani and Hylander (2012) mention a ‘professional benefit’, focussing on the personal benefit gained by working together. Such a benefit could be, for instance, understanding their own and other professionals’ attitudes and values in terms of family support (Psaila, Fowler et al., 2014). A stronger cooperation is also associated with improving the work-life balance because the responsibility of providing adequate care is shared by the other professionals involved (Peterson et al., 2007). Whether or not the cooperation between the professional groups is felt to be a benefit for the individual profession depends on its position in the care-providing system. Whereas Swedish midwives are the first and middle links in the chain of care as a result of their mandate to provide care during pregnancy and up to a week postpartum, child health care nurses caring for children up to 6 years of age are the final link in the chain of care. Child health care nurses emphasise that they rely on adequate information being supplied when they take over the care for families from the midwives. Midwives however report that they experience no direct benefit from working together with child health care nurses (Barimani & Hylander, 2008).

Several studies emphasise the benefits that cooperation brings for those who make use of the care system (Barimani & Hylander, 2008; Barimani & Hylander, 2012; Homer et al., 2009; Nagel-Brotzler et al., 2005; Peterson et al., 2007; Psaila, Fowler et al., 2014). This is shown in the high quality of the care provided (Peterson et al., 2007; Ratti et al., 2014). The successful treatment of women with psychiatric disorders in early motherhood depends on interdisciplinary cooperation (Nagel-Brotzler et al., 2005). According to 25 representatives of Canadian midwives, physicians, and nursing associations, care provided by various professional groups working together gives the women an improved access to maternity services as well as options regarding the providers. The study’s participants hope that collaborative care provision will contribute to women with a low maternity risk, receiving adequate care that is intended to reduce the number of medical interventions (Peterson et al., 2007).

Midwives and child health care nurses who took part in a Swedish study do express the effective networking between antenatal and postnatal care and child health care services as being a benefit for the women (Barimani & Hylander, 2008), as in that both professional groups are seen as one unit (Barimani & Hylander, 2012). The parents benefit from a consensus between the groups, which also prevents an impression of being lost in the chain of care (Barimani & Hylander, 2008). Psaila et al. (2015) describe how effective collaboration at the intersection of maternity services and child and family health nursing becomes a positive experience for the families involved. Midwives and child and family health nurses express the opinion that this supports the building of positive relationships with the families, resulting in a longer-term connection to the providers (Psaila et al., 2015).

Communication influences the intensity of the cooperation (Psaila et al., 2015) and can facilitate the transition from one care provider to another (Homer et al., 2009). The communication between the professional groups is on either a formal or an informal level, both of which are considered important for the promotion of interprofessional cooperation (Munro et al., 2013; Murray-Davis et al., 2011; Psaila et al., 2015). This means that information can be exchanged during official meetings, for instance, or perhaps in the tearoom during a break (Barimani & Hylander, 2012). Numerous studies have described meetings between the various groups of professions to be conducive to cooperation (Barimani & Hylander, 2008; Edvardsson et al., 2011; Homer et al., 2009; Miers & Pollard, 2009; Schölmerich et al., 2014; Schmied et al., 2015), enabling the faces to be put to the voices that are already known (Barimani & Hylander, 2008) and ensuring that the participants understand each other (Miers & Pollard, 2009). Meetings can provide an insight into activities in other professions and also reveal synergies (Edvardsson et al., 2011) or counteract any lack of communication or any mistrust that might exist between the professional groups (Ratti et al., 2014). Only a few studies take as their theme a negative or hostile attitude of the study population towards meetings with groups of other professionals (Barimani & Hylander, 2008).

In addition, communication between various professional groups can be supported by making combined offers of care provision (Ratti et al., 2014), by locating services from different professional groups at one particular location (Barimani & Hylander, 2008; Homer et al., 2009) and also by setting up an electronic information exchange system (Psaila, Fowler et al., 2014). An electronic system of referrals is an effective method of ensuring communication between the hospital-based and community maternity services (Psaila, Fowler et al., 2014). However, Homer et al. (2009) have reservations about this, stating that the non-verbal exchange of information could lead to restricted contact between those involved, resulting in insufficient knowledge about other professions.

A number of studies broach the issue of communication problems between the groups of professions and their effect on collaboration (Barimani & Hylander, 2008; Homer et al., 2009; Nagel-Brotzler et al., 2005; Psaila, Kruske et al., 2014; Schölmerich et al., 2014; Schmied et al., 2015; Shaw, 2013; Smith et al., 2009). Poor communication jeopardises the efficacy of working relationships (Murray-Davis et al., 2011; Psaila et al., 2015) and is identified as a ‘key barrier’ (Shaw, 2013), ‘key problem’ (Psaila, Kruske et al., 2014) or as ‘an elephant in the room’ (Schmied et al., 2015). Midwives experience this lack of communication more often as an impediment for collaboration in the context of maternity care than obstetricians or family physicians do (Smith et al., 2009). Three studies present an overview of the communication difficulties between midwives and physicians (Nagel-Brotzler et al., 2005; Schölmerich et al., 2014; Shaw, 2013), showing that pregnant women may take on an active, communicative-supportive role by transferring information between the professional groups (Schölmerich et al., 2014).

Interprofessional working relationships are often greatly influenced by the perspectives on care provision taken by representatives of different professional groups: they can lead to a mutual goal or they can be a source of tension (Murray-Davis et al., 2011). Midwives and child health care nurses emphasise the relevance of perspectives when working together, particularly with regard to the transition between antenatal care, postnatal care, and child health care. A ‘chain of care perspective’, which is characterised by viewing the entire chain of care, includes the ability to collect knowledge about the other professions in the chain aside from one’s own care service obligations. Such a perspective may facilitate a joint action between the professional groups; ironically, joint action is simultaneously a prerequisite for such a perspective (Barimani & Hylander, 2012). In contrast, a ‘link perspective’, in which one’s own abilities are prioritised and tasks are not seen as part of a comprehensive care provision system, has a restraining influence on the cooperation (Barimani & Hylander, 2008; Barimani & Hylander, 2012).

Some studies address topics of cooperation from different perspectives of the professional groups (Barimani & Hylander, 2008; Barimani & Hylander, 2012; Munro et al., 2013; Murray-Davis et al., 2011; Psaila, Kruske et al., 2014), others focus explicitly on the differing perspectives between midwives and physicians (Ratti et al., 2014; Schölmerich et al., 2014; Shaw, 2013; Smith et al., 2009; Vedam et al., 2012), which result in tension and conflict, mistrust, and a lack of respect (Ratti et al., 2014). Whereas 60.7% of the midwives who took part in a quantitative survey described different perspectives as being a central impediment for interprofessional cooperation with physicians, only 46.5% of the obstetricians and 23.3% of the family physicians asked were of the same opinion (Smith et al., 2009). Different perspectives between midwives and physicians are also revealed with regard to the safety of home births (Munro et al., 2013; Vedam et al., 2012). In consultations between both professions, this leads to a mutual feeling of ‘discomfort’, as seen in a quantitative survey by Vedam et al. (2012), in which a total of 825 midwives, obstetricians, and family physicians took part. While 71.2% (n = 99) of the family physicians and 82.6% (n = 194) of the obstetricians state that home births are not as safe as clinic births, only 1.1% (n = 5) of the midwives are of the same opinion. Both professions believe that their views are evidence-based.

Interprofessional relationships are vital for successful collaboration (Clancy et al., 2013; Homer et al., 2009; Munro et al., 2013; Psaila et al., 2015; Psaila, Fowler et al., 2014; Psaila, Kruske et al., 2014). They are the key to success for innovations at the interface between maternity services and child and family health services (Psaila, Fowler et al.,2014).In order to gain a deeper understanding of the working relationships between midwives and child and family health nurses, representatives of all groups were given a list of professions and asked to tick the three groups with whom they work together most frequently. As a rule, midwives work together regularly with associated health professions; child and family health nurses, and paediatricians are the next in line. Creating a professional relationship is challenging because it often takes a long time to develop; furthermore, it is difficult to maintain existing relationships, though organisational support can strengthen them. In terms of the intensity of collaboration, midwives and child and family nurses give a higher rating to the relationship dimension than to the organisational factors (Psaila et al., 2015). This is confirmed by 1,418 members of health and social services who took part in a cross-sectional study, giving leadership and formalised structures a lower ranking than interprofessional relational factors (Clancy et al., 2013).

Working relationships between midwives and physicians are the subject of other studies (Murray-Davis et al., 2011; Pollard, 2011; Skinner & Foureur, 2010). In a quantitative survey (Skinner & Foureur, 2010), midwives rated these as being excellent, but a qualitative study indicated that midwives experience their working relationships to physicians diversely (Pollard, 2011). On the one hand, they perceive their own profession on an equal footing with that of obstetricians in the health care system, describing their relationships as equitable; on the other hand, they endeavour to attain professional recognition in a hierarchical system. This can lead to friction, for instance, when midwives are obliged to observe certain paediatric guidelines that they deem inappropriate (Pollard, 2011).