13 Midwife as Researcher
Eileen K. Hutton, BSc, MSc, PhD
The generation of knowledge is a defining characteristic of professions. As in other health care fields, midwifery research helps to describe the profession and provides evidence for its activities. (1) This chapter provides a historical context for midwives as researchers, describes the research process, and provides a rationale for midwives to undertake research. A description of the role for midwives as they generate profession-specific knowledge is provided.
13.1 History of Midwives in Research
Midwives have a long history of generating new information and of communicating this information to enhance the quality of care provided by their colleagues. As clinicians, midwives are natural researchers; they ask questions about the care that they provide, critique clinical observations, and shape practice based on these findings. Today we describe this activity as reflective practice, and going far into midwifery history we have examples of midwives who undertook this same activity and contributed to the knowledge base of the profession.
13.1.1 Catharina Schrader (1693-1746)
A Flemish midwife who cared for over 4,000 women and newborns and carefully documented her the care she provided (Figure 13-1). Her records show that over her many years of practice she prepared summaries of best management so others might benefit from her observations.
Did You Know?
Catharina Schrader’s notes were published in a memoir titled ‘Memoryboeck van de Vrouwens. Het notitieboek van een Friese vroedvrouw 1693-1745’. Her notes were meant to serve as a financial record, patient registry and a guide to future midwifes. The notes were translated into English in a book titled ‘Mother and child were saved. The memoirs (1693-1740) of the Frisian midwife Catharina Schrader.’
13.1.2 Angélique Marguerite Le Boursier du Coudray (1712-1794)
In 1759, after practicing midwifery for ten years in Paris, King Louis XV named Mme du Coudray (Figure 13-2) as, the King’s Midwife. She was well paid to travel the country and provide what we would now call continuing education to both urban and rural midwives. She authored a textbook for use by midwives, and invented and developed teaching manikins (Figure 13-3), which revolutionized midwifery education. It is reported that by 1780 two-thirds of all French midwives had studied with Mme du Coudray. The teaching tools and approaches that she developed speak to both her role as an educator, and demonstrate her early role in knowledge translation.
Did You Know?
Many of Mme Du Coudray’s obstetrical teaching manikins can still be seen in the Musée Flaubert et d’histoire de la médecine in Rouen, France.
The life-like teaching models were made of leather and in very many ways are similar to the torsos in use now that are made of plastic. The models were easily transported and could demonstrate the basic manoeuvres of normal birth, as well as manoeuvres involved when complications associated with variations in position are encountered such as occipital posterior, or breech presentations. Approved by the French Academy of Surgeons in 1758, her models are confirmed to be the first approved teaching model for simulated learning in obstetrics.
To learn more about Mme du Coudray, visit:
13.1.3 Ethel Margaret Burnside (1877-1953)
Midwife Burnside was the first woman to be appointed as chief health visitor in the county of Hertfordshire, on the northern border of London, UK. Concerns had been raised about the general health of children in the country, and Burnside established a standardized record to be used for childbirth, newborn and early child hood care. These records included birth weight, method of feeding and records of each child’s ongoing weight, illnesses and general development for the first year of life. Her team of midwives and nurses used these standardized forms at all of their clinical visits and the data was subsequently transcribed into ledgers at the county office. This system was in place from 1922 until 1948 and provided a wealth of information that was later used to link birth outcomes and early childhood experiences to adult outcomes and provide the basis for David Barker’s Hypothesis, which is now referred to as the Developmental Origins of Health and Disease or the DOHaD theory.
To read more about the DOHaD Theory, visit:
13.2 Midwives & Research
Midwives, like all health professionals, have come to appreciate the role of research in informing best practice. Much of the information used by midwives to guide clinical practice can be garnered from research findings of other professions, such as nursing, and medicine – particularly obstetrics and neonatology. So, one might question whether specific midwifery research is needed and further, whether it should be midwives who conduct the research.There are, of course, many reasons that midwives should be involved in primary research, three of the fundamental reasons include:
- Midwives ask questions that are of unique importance and relevance to improving care to women and infants during pregnancy and childbirth
- Other health providers may not ask the questions to which midwives need answers
- Midwives have a professional responsibility to generate knowledge relevant to their specialty
Two additional reasons for midwives to be involved in generating knowledge relate to the nature of midwifery. The first reason relates to the magnitude of effect that can result from an absence of knowing. Internationally, pregnancy and childbirth are considered normal, physiologic functions and most women giving birth are considered to be at low risk of associated complications and are thus under the care of midwives; therefore, if midwives get something in their care wrong, it has the potential to affect large numbers in the birthing population. For example, for many years clamping of the newborn umbilical cord immediately following birth was encouraged as part of a postpartum hemorrhage prevention strategy. Early in the 21st century adequate research emerged to suggest that this action was detrimental to newborns, affecting them for as long as six months following birth. Midwives played an important role in generating this research: Judith Mercer, a midwifery scientist in Boston led the earliest research on delayed cord clamping involving very preterm infants. The results of her work has changed practice for these very vulnerable infants. Eileen K. Hutton, a Canadian midwifery researcher published the first systematic review of delayed cord clamping in the full term infant. (2) Diane Farrar, a British midwifery researcher, studied the transfusion effect of delaying cord clamping by weighing infants immediately following birth. (3) These works contribute to the changed and changing guidelines. The strategy of clamping the umbilical cord within seconds of birth had been used for years without any testing and has impacted generations of infants.
Reflective Practice Question
Why do you believe we need midwifery research? Why do you think it is important that midwives conduct research?
Judith Mercer discusses how observation from practice can lead to research in the following interview:
The second reason for midwives to undertake research has more to do with the evolution of obstetrical practices over the last century, many of which have become ‘usual care’ without research evidence of their benefit, and perhaps more concerning, no evidence on their potential harm. For example, electronic fetal heart monitoring (EFM) was first developed in the 1970s and introduced to routine care with the hope that it would identify fetuses who were experiencing difficulty during labour. At the time, there was no research to demonstrate its effectiveness in screening for at risk fetuses among low risk labouring women. It is still used in many settings today, yet no studies since have been able to show if or how EFM improves outcomes for these neonates. (4) However, EFM is associated with higher rates of intervention, including increased rates of cesarean birth. (4) Even in the absence of evidence of benefits, and strong evidence that, routinely used, EFM is harmful, it is very difficult to change practice.
Did You Know?
Women and infants have been exposed to many practices in maternity care that have had both short and long term detrimental effects. As late as the 1970s, because birth was treated as a surgical event, all women routinely received an enema in labour to cleanse the birthing site. Women were placed in stirrups and were covered in sterile drapes to maintain a sterile area around the birth canal. Women also routinely received an episiotomy in order to ease the birth of the infant across the perineum. This was meant to prevent uncontrolled damage to the perineum as it was thought that a surgical incision would heal better than a ragged tear . Preparing the surgical site for the episiotomy meant that the perineal area had to be shaved in early labour, and further cleansing of the birthing site involved swabbing the perineum and vaginal cavity with cleansing agents such as povidone-iodine (trade names: betadine®, or proviodine™ and others). All of these activities likely changed the normal flora that the infants were exposed to during the birthing process. We are just now beginning to understand how this flora might be important to the life-long health of the infant. (5)
Midwifery-specific research helps shape the profession and makes it responsive to the current needs of society. Although some might argue that midwifery has been slower than many other professions to undertake research, in the last number of years considerable headway has been made. Some very influential research papers have been shaping contemporary midwifery. For example, the Cochrane review (6) reporting that continuity of midwifery care models improved outcomes for women and babies provided a powerful basis to support the reintroduction of a model of care that in many jurisdictions had all but disappeared. Research papers on homebirth from the UK, the Netherlands and Canada have provided solid evidence that has altered national guidelines to state that care providers should, ‘explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth.’ (7) These are important research papers because they have helped to ensure that women and families who want to choose a birth at home have this option available to them. In addition to enhancing care and broadening care options for women, midwifery lead research influences the way the profession is perceived. The role of positive research outcomes helps maintain the credibility of the profession of midwifery in a way that should not be underestimated.
The Lancet Series on Midwifery published in 2014 enhanced the understanding and credibility of midwifery as a profession. The series reported on a major research initiative undertaken by world leaders in midwifery research to develop a research framework. Their project also outlines priority research areas for midwifery globally and describes how investing in midwives will enhance quality of care in the areas of reproductive, maternal, newborn and child health.
The Lancet Series on Midwifery can be found here: http://www.thelancet.com/series/midwifery
13.3 The Research Process
The research process has been widely described in the literature and may vary somewhat depending on the field of study. In general, it refers to a systematic approach to collecting information, sometimes called data, which is then analyzed to answer a question of interest. The research process is briefly described below.
In health sciences, questions are very often a narrow, clinical questions such as, ‘When is the best time to place the umbilical cord clamp on a healthy term infant following birth?’ Other questions of interest to clinicians may be broader types of research questions such as, ‘How does interprofessional education during training affect working relationships among midwives and obstetricians?’ or ‘What do pregnant women understand about weight gain in pregnancy?’ In the research process the development of the initial question is a very important step in the process, and it is then refined following a careful review of the literature so that the question can be framed in terms of what is already known about the subject.
Once the question is formed and refined the most appropriate research method to answer the question must be determined. For example, a researcher might choose a randomized controlled trial to test a particular approach or an intervention in comparison to what is in current practice. Sometimes random assignment of an intervention is not possible, feasible or even ethical. In such cases, a cohort study design is an alternative approach that might be considered. In the case of determining opinions or beliefs about a topic qualitative methods may be appropriate. Once the method is settled upon, the study design is written up into a study protocol that will inform all the details of how the study will be carried out.
The next step is to collect data to answer the study question. This might involve recruiting and interviewing participants or administering questionnaires, for example. Another potential data source is data collected as part of population databases, like the Better Outcomes Registry & Network (BORN) database to which Ontario midwives contribute. To ensure accuracy of the data the dataset is cleaned and prepared by undertaking logic checks such as date of birth follows date of entry to care. The cleaned dataset can then be used for analysis and the results interpreted.
The final step in the research process is knowledge translation whereby new information is disseminated, usually in the form of a scientific manuscript, ideally published in a peer reviewed, or refereed journal. Information is also often shared at scientific conferences to research peers, and at conferences for practitioners when there is direct clinical application of the findings.
Visit the BORN website here: https://www.bornontario.ca/
13.4 Funding Research & Researchers
Obtaining grant funding is typically a highly completive process and in many respects shapes and limits the research that is undertaken. Thus, grantsmanship is an important skill to master for any midwife entering the research arena as a primary researcher. Much time is spent on applying for grants, many of which are not successful in the grant competition process. For midwives with academic positions, or other positions focusing on research, maintaining an up-to-date academic curriculum vitae (CV) is essential. The CV is the credential used to move through the promotions process, but most importantly it is the document that provides reviewers of research grant proposals with information needed to evaluate research capacity – the ability to undertake the research being proposed to ensure the project under consideration for funding in is likely to be done, and done well. Research grant reviewers consider the researcher’s:
- Educational background
- Awards of distinction received during academic training or research career
- Number and type of grants previously received
- Number of peer reviewed publications including those resulting from grants
- Number of first authored papers
- Publications by the quality of journal where the work is published
- Number of times the publications has been cited
- Presentations – peer reviewed, keynote invitational, oral, poster
- Presentation awards received
- Number of graduate students that have been supervised, awards those students obtained
13.5 Contributing to Research
Research has become increasingly sophisticated and typically requires specific expertise and outside funding to undertake. Nonetheless, there are a variety of ways in which all midwives can contribute to scientific research endeavours.
Midwives practitioners are experts in the provision of maternal child care and have a major role to play as part of the research team. Research questions often arise from day-to-day practice, and although a midwife may not lead a research project, communicating an important question and working collaboratively on the development of a project to answer it can make a significant contribution to increasing knowledge in the field. During the development phase of a research protocol midwives can provide insight to ensure that the study design is suited to answer the research question being asked. They are best able to determine if the proposed methods for things, such as recruitment and implementation of the study protocol, are feasible in the practice setting. Midwives are also the primary route through which clients are recruited from the practice setting.
Many research questions can be answered using population databases. Midwifery databases have been used to answer very specific questions such as to determine the outcomes of planned home birth. The quality of the research in these cases depends entirely on the quality of data input at the midwifery practice level; thus midwives have a critical role in deriving these data. At the time of entry of data into population data sets, it may be difficult to justify the value of time spent on the activity, however, studies that have resulted from using these data have been essential in informing, maintaining, and enhancing choice for women regarding matters such as place of birth. (8,9)
An example of a data base study can be found here: http://pediatrics.aappublications.org/content/pediatrics/early/2014/09/17/peds.2014-1146.full.pdf
Mme du Coudray, who was introduced earlier in this chapter demonstrated that she understood the value of what we now call KT when she travelled widely with her teaching models to upgrade practitioners level of clinical knowledge. The role of KT is being increasingly recognized as an critical component of successful research. It has become a standard that research proposals include endorsements or partnerships with knowledge users. It is also increasingly common to have interprofessional research teams. Midwives can participate in research projects led by midwife researchers or by researchers from other professions or disciplines, contributing a midwifery perspective to every aspect of the research. Once new knowledge is gained, it will be of little or no use if practitioners do not use it. By working with their professional associations to develop clinical practice guidelines, or in their own practices to prepare practice protocols, midwives can contribute to knowledge translation. Midwives should also participate in presenting new information to colleagues and learners, for example at hospital rounds.
13.5.2 Research Team Members
When midwives generate a research question, they may play a key role as either a principal investigator, co-investigator, or a co-applicant on research project. Sometimes midwives have particular expertise that they bring to the research question being asked, and may be invited to participate on a project on that basis. Alternatively, midwives with additional research training may wish to work in the capacity of salaried research assistants or coordinators. Research projects often require research assistants or research coordinators to help to manage the undertaking, and these positions can be funded by research grants. In some settings, such as Australia and the UK, staff midwifery research positions are available in hospitals or other organizations involved with health care. The role of the midwife researcher in these positions varies, but may include assisting with external research projects, initiating and running the daily operations of research projects, and knowledge translation for midwives and other interprofessional members of the obstetrical care teams.
13.5.3 Clinician Scientist
Clinician scientist is the term frequently used to describe those who both lead research endeavours and provide health care. The term ‘scientist’ is inclusive and refers not only those who are doing basic science, but to those doing epidemiological work, or using qualitative approaches; it includes social scientists, bio-scientists, and many others.
The division of time spent by clinician scientists in research and in clinical practice will depend on the funding arrangement that supports their salary. Typically, a clinician scientist focuses on health research or basic research as it applies to a medical field. However, such a scientist could have training in other specialties, such as sociology or anthropology, and make contributions to knowledge of care provision. Clinician scientists typically understand research questions relevant to clinical practice, and can play a role in transferring findings from research bench-to-bedside, closing this breach with effective knowledge translation. Their contribution to the profession is key in ensuring generation of the knowledge needed for best clinical practice. Opportunities for midwifery clinical scientists are more common in the UK and Australia than in Canada at this time where such opportunities are rare. Professions such as medicine have well identified pathways to become a clinician scientist– in Canada, for example, there are two routes:
- The Royal College of Physicians and Surgeons approved doctor of medicine (MD)/ doctor of philosophy (PhD) degree program where the undergraduate MD and PhD programs are combined
- The Clinician Investigator Program where PhD studies are undertaken concurrent with the postgraduate medical education (residency). (10)
Usually a clinician scientist is prepared for research at the doctoral level in their area of specialty. A qualified midwife might have additional training in health economics, or in clinical epidemiology, or in bioethics, for example. Their research might specialize in studying clinical interventions (e.g. use of sterile water injections for pain management using methods such as randomized controlled trials) or using population databases to answer questions about health care utilization (e.g. comparing home and hospital birth outcomes). They may also use qualitative methods to explore a particular health topic (e.g. the needs of obese pregnant women or the experience of uninsured immigrant women seeking maternity care).
In the academic setting and within the research milieu, the expectation is that a researcher will build a ‘body of research’. This means that the research undertaken by a particular researcher will, over time, contribute to a growing understanding of a particular topic. That is, each small study builds to try to understand a particular phenomenon or problem of interest. In specialties like midwifery, this expectation that researchers build a ‘program of research’, such that researchers develop expertise in particular areas and build on the work in their area of study over their careers. This body of research is considered when research contributions are being evaluated for funding purposes or for tenure and promotion within the academic setting, so it is important that researchers understand the expectations of the system in order to increase the likelihood of career success.
13.6 Building Research Capacity
Despite the examples of early midwife researchers given at the beginning of this chapter, in most settings, midwifery research has not developed alongside clinical practice. Evidence derived from research has become the expected underpinning for contemporary clinical practice, thus imposing on the profession a sense of urgency to generate knowledge. Research takes time to arrive at answers and the incongruence of a need for knowledge and the time required for knowledge generation can cause frustration.
Research is expensive to undertake and can be seen as using scarce resources without immediate benefit. (10) Lack of infrastructure support for midwifery researchers – including access to financial support during advanced research training; balancing research with other career demands; and absence of research infrastructure for funding, publications and presentation of findings is also common. Perhaps as a result of these factors, development of research capacity is a challenge faced by the midwifery profession in many jurisdictions. (11) As a result, Canada currently has midwives who may do some research as part of academic work with teaching and practice but few who commit significant time to the research process as career research scientists. The profession needs to develop strategies to enhance the opportunities for growth of research generally, and particularly to address the shortage of midwifery clinician scientists.
The role of a good mentor in the success of a researcher cannot be underestimated. The requirement for good mentoring begins in the early stages of acquiring additional research skills. Making careful choices around the educational program that is selected for advanced degrees, with particular attention to the choice and role of supervisors during this process will pay off. Characteristics of a good mentor include one who will (12):
- Provide support in securing resources needed
- Provide opportunities to enhance learning, develop skills and gain experience
- Provide advice without expectations
- Protect the mentee in transiting academic pathways – either as learner or as new researcher
Relative to other professions, midwifery has proportionately fewer research scientists, and those entering the realm of research may find that they need to look outside of the midwifery profession for mentors. Although this might be viewed as a limitation, it can also be a potential strength. A mentor who is an expert researcher outside of midwifery may in fact be able to provide excellent, and unbiased mentoring.
Professions like midwifery often prioritize clinical practice as their core business to the extent that the needs of researchers are ignored. However, it is incumbent upon the profession to create midwifery specific knowledge, resulting in a professional obligation to support researchers undertaking this needed work. In order to continue to provide the best possible care to clients and their infants, the profession needs researchers who will think critically and creatively and undertake high quality research, in order to make meaningful changes to practice through the generation of new knowledge. Midwifery scientists have an essential contribution to make to the sustainability of the profession and it is contingent upon individual midwives, professional associations, regulatory agencies and funding bodies to support this important activity.
- Higgins I, Parker V, Keatinge D, Giles M, Winskill R, Guest E, et al. Doing clinical research: The challenges and benefits. Contemp Nurse. 2010;35(2):171–81.
- Hutton EK, Hassan ES. Late vs Early Clamping of the Umbilical Cord in Full-term Neonates. JAMA [Internet]. 2007 Mar 21 [cited 2017 Aug 1];297(11):1241. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17374818
- Farrar D, Airey R, Law GR, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: Weighing babies with cord intact. BJOG An Int J Obstet Gynaecol. 2011;118(1):70–5.
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- National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies [Internet]. NICE; 2014 [cited 2017 Jul 31]. Available from: https://www.nice.org.uk/guidance/cg190
- Darling EK, Ramsay T, Sprague AE, Walker MC, Guttmann A. Universal Bilirubin Screening and Health Care Utilization. Pediatrics [Internet]. 2014 Oct 1 [cited 2017 Aug 1];134(4):e1017–24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25246625
- Hutton EK, Cappelletti A, Reitsma AH, Simioni J, Horne J, McGregor C, et al. Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ [Internet]. Canadian Medical Association; 2016 Mar 15 [cited 2017 Aug 1];188(5):E80-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26696622
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- Sackett DL. On the determinants of academic success as a clinician-scientist. Clin Invest Med [Internet]. 2001 Apr [cited 2017 Aug 1];24(2):94–100. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11368152
A photograph taken in a museum of a cloth dummy. It appears to be a beige, coarse material, and stitching can be seen throughout. The dummy is a basic model of the female form from about the bellybutton to the mid-thigh. the thighs are spread open, and held up by stirrups, displaying the sewn vulva. Out of the vaginal opening (a split in the material), a sewn newborn is being birthed, with its head and arms already out. [Return to Figure 13-3]