In Cyprus, ‘midwifery is dying…’. A qualitative exploration ofmidwives' perceptions of their role as advocates for normal childbirth

Eleni Hadjigeorgiou, RN, RM, BSc (Hons), MSc, PhD (Midwifery Educator)a,n,Kirstie Coxon, RN, BSc (Midwifery), MA, PhD (Research Associate and NIHR KnowledgeMobilisation Fellow)b

a Department of Nursing, School of Health Sciences, Cyprus University of Technology, 15, Vragadinou, 3041 Limassol, Cyprusb King's College London, Division of Women's Health, Women's Health Academic Centre, 10th Floor, North Wing, St Thomas' Hospital, Westminster BridgeRoad, London SE1 7 EH, UK

a r t i c l e i n f o

Article history:Received 6 February 2013Received in revised form5 August 2013Accepted 8 August 2013

Keywords:MidwivesPerceptionsAdvocacyNormal birth

a b s t r a c t

Background: advocacy has been identified as vital for improving maternal and newborn health. In manycountries, midwives struggle to advocate for women; in Cyprus, there has been no research intoperceptions of advocacy amongst midwives.Aim: this study provides an exploration of the perceptions of midwives as client advocates for normalchildbirth in Cyprus.Design: a qualitative approach was adopted, using participant observation and semi-structured inter-views with a purposive sample of twenty experienced midwives. A thematic approach was taken for theanalysis.Findings: five main interconnected themes emerged, two of which, ‘Lack of professional recognition’ and‘Deficiencies in basic or continuing education’ presented barriers to midwives' adoption of an advocacyrole. Three themes reflected structural factors that also discouraged midwives from acting as advocates:these were ‘physician dominance’, ‘medicalisation of childbirth’ and ‘lack of institutional support’.Conclusion: advocacy is a demanding and challenging role and midwives should be empowered to feelconfident in undertaking this role through continuing professional education programmes and profes-sional recognition. In order to be effective advocates, midwives needed to be recognised and valued bythe public and by other health professionals as equal partners within the multidisciplinary team.However, midwives in Cyprus find themselves in difficult situations when advocating normal childbirthdue to medical domination of the health services, medicalisation of childbirth and inadequateinstitutional support.Implications for practice: in this setting, midwives need to gain professional recognition, to have moreeffective basic and continuing education programmes and receive better support from managers andpolicy makers in order to become advocates for normal childbirth.

& 2013 Elsevier Ltd. All rights reserved.

Introduction

Advocacy within maternity care is central to midwives' practicein supporting women to achieve a normal birth (McCourt et al.,2006; Simmonds, 2008; Finlay and Sandall, 2009). Advocacy hasbeen identified as vital for improving maternal and newbornhealth, and midwives' commitment to advocating normal child-birth is enshrined in the ICM's statement on the internationalphilosophy of midwifery care (ICM, 2005a). The concept of

advocacy may be interpreted in various ways depending oncontext and the needs of a client or population. In this paper,‘advocacy’ is understood as it is outlined by Walsh (2011, p. 489) inrelation to normal birth as the practice of ‘informing, supportingand protecting women, acting as an intermediary between themand obstetric and other professional colleagues, and facilitatinginformed choice’. Midwives are obliged to respect human dignity,treat women as persons with full human rights and advocate forwomen so that their voices are heard (ICM, 2005b). However,research evidence shows that in many countries, midwives strug-gle to advocate for women (Munro and Spiby, 2003; Downe, 2006;McCourt, 2006; Homer et al., 2009). This is often attributed tofactors such as the relative power of obstetricians during birth, thesocio-cultural medicalisation of birth and ‘accepted’ labour ward

Contents lists available at ScienceDirect

journal homepage: www.elsevier.com/midw

Midwifery

0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.midw.2013.08.009

n Corresponding author: Department of Nursing, School of Health Sciences,Cyprus University of Technology, 15, Vragadinou, 3041 Limassol, Cyprus.

E-mail address: eleni.hadjigeorgiou@cut.ac.cy (E. Hadjigeorgiou).URL: http://www.cut.ac.cy (K. Coxon).

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎

practices of routine intervention, and a lack of support for normalbirthing within the health care system (Simmonds, 2008). On theother hand, factors known to facilitate advocacy for normal child-birth include effective basic and continuing midwifery educationand professional recognition of midwives (Goldberg, 2003; Finlayand Sandall, 2009).

Background

A period of rapid change in midwifery care and increasedprofessional awareness of evidence led to recognition that somebirth interventions are over-used, and that routine use does notbring benefits to women or infants (Enkin et al., 2000; Beech, 2001;Devane et al., 2010). In order to offer safe and competent midwiferycare and advocate for normal childbirth, midwives need effectivebasic and continuing education (Alsop, 2002; O'Connor and Kelly,2005). Appropriate competence and knowledge creates high levelsof self-esteem and self-confidence amongst midwives (Willard,1996; Ingram, 1998; Mallik, 1998; Timmins and McCabe, 2005)and prepares midwives to be assertive, empowered and recognisedas professionals in their own right (Timmins and McCabe, 2005;Barr and Low, 2012). Professional recognition is closely related toeducation, and together these factors support and facilitate mid-wives' advocacy of women (Davis, 2000; Odom, 2002; Williams,2006).

However, physician dominance, medicalisation of childbirthand insufficient numbers of midwives in the workforce all presentknown barriers to client advocacy (Etuk, 2001; Homer et al., 2001;Johanson et al., 2002; Odent, 2002; Negarandeh et al., 2006).Physician dominance and medicalisation of childbirth have beendescribed as prominent in western society (Arney, 1982; Davis-Floyd, 1987; Davis-Floyd, 1994; Davis-Floyd and Sargent, 1997;Davis-Floyd, 2001), although the extent of obstetrician influencevaries between countries and appears to be mediated by nationalpolitics and cultures, intra-professional relationships and historicalorganisation of privately and publicly funded care (DeVries et al.,2001; Murray and Elston, 2005). In some countries, midwiveswork only in hospitals and are obliged to follow certain medicalprotocols and procedures (Kitzinger, 2000, 2005); opportunities toact in women's interests where this would lead to care that is notprescribed by protocol may be limited, or such actions may beunsupported by midwives' managers and colleagues. Manywomen regard medicalised care with obstetric interventions asthe ‘normal’ way to give birth (Downe et al., 2001) and some areconvinced that births should always take place in hospital withobstetricians present (Davis-Floyd, 1994; Luthy et al., 2004;Inhorn, 2006). As middle and high-income countries becomeincreasingly dependent on medical interventions and surgicalbirth, there is a danger of a loss of belief in women's ability togive birth naturally (Savage and Francome, 1993; Kennedy andShannon, 2004) and of a loss of midwives' and obstetricians' skillsand confidence in normal birthing.

Furthermore, in the hierarchical structures of the hospital,obstetricians are usually considered to hold the most valuedknowledge and skills, and have consequently acquired substantialinfluence in determining what is considered normal during birth(Friedson, 1970; Arney, 1982; Luthy et al., 2004). Midwives alsoneed organisational support from their managers and from withinthe health system (Thompson, 2004) in order to be effectiveadvocates for women and for normal birth. Organisational supportentails adequate staffing levels, correct skill mix and a clearlystated philosophy which is consistent with the goals of supportingwomen to achieve normal birth.

The World Health Organization (WHO) acknowledges mid-wives' contribution to safe motherhood and proposes midwives

as the lead health professional to promote normal childbirth.Evidence from a Cochrane review demonstrates that midwife-ledcare is both safe and beneficial for women, and increases thelikelihood that women will be looked after by a midwife they havecome to know and have a spontaneous vaginal birth (Hatem et al.,2008). However, in many Central and Eastern European countries,including Cyprus, obstetricians are the lead health professionals atbirth (WHO, 1996, 1999; Wagner, 2001; Kitzinger, 2005). A recentreport identifies that over 50% of births in Cyprus are by caesareansection, representing one of the highest rates in Europe and onewhich is double that of the Nordic countries (EURO-PERISTAT withSCPE and EUROCAT, 2013). This calls into question the effective-ness of maternity care provided to women in Cyprus, and suggestsa clear need for support from midwives and obstetricians, policymakers and educators for normal birth in this country.

Midwifery education and practice in Cyprus

In Cyprus there is no formal basic and ongoing education formidwives. Instead, single intake basic and post-graduate coursesare created on an ad-hoc basis, in response to demand from theMinistry of Health, and potential applicants have no way ofknowing when these may be offered. From 1933 to 1951, midwivescould attend obstetric lectures, but a full education programmewas not available. From 1960 to 1980, the Cyprus Nursing andMidwifery School occasionally offered a direct-entry two yearmidwifery programme. During this period, a post-basic midwiferyprogramme was also offered intermittently for senior midwiveswho had previously completed a three year nursing programme. In2007 the Nursing and Midwifery School closed, and the post-basic18 month programme has since been provided intermittently atthe Cyprus University of Technology, following completion of a BScin nursing. In Cyprus there are 155 obstetricians and 200 midwivesproviding maternity care to a population of 862,011 with approxi-mately 9622 births each year (WHO, 2013). Midwives in Cyprushave little influence on formulating public health policies, andthere is a strong medical influence in the provision of antenatal,intrapartum and postnatal care. All births in Cyprus take place inpublic and private hospitals. Maternity departments provideobstetrician-led care using medical protocols, and the architectureand environment are not conducive to supporting normal birth.There is routine use of labour and birth practices includingrestriction of food and liquids during labour, widespread use ofintravenous fluids, frequent vaginal exams, continuous electronicfetal monitoring, epidurals and episiotomy (Hadjigeorgiou et al., 2012).

Despite advocacy becoming an accepted and integral attributeof midwifery practice in many countries (Randle, 2004), fewstudies in the midwifery and nursing literature have exploredcaregivers' perspectives on advocacy in the context of childbirth(Simmonds, 2008). In Cyprus there has been no research intoperceptions of advocacy amongst midwives, and the researchundertaken during this study addresses this gap in the literature.The research explored midwives' perceptions of their role asadvocates for normal childbirth, and the aim of this article is topresent factors that were found to facilitate or inhibit normal birthadvocacy amongst midwives working in public hospitals in Cyprus.

Methodology

A qualitative approach was adopted for this study; the designused a mixture of participant observation and individual inter-views. Qualitative methods were considered most appropriatebecause these provide an opportunity to gain rich knowledgeand insights about individuals' lived experiences (Mason, 1996;

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎2

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

Holloway and Wheeler, 1997). Participant observation also allowedthe researcher to observe first-hand midwives' experiences ofproviding maternity care in Cyprus maternity hospitals; this shedlight on the environment and culture of care (Polit et al., 2001) andhelped clarify why clinicians practice as they do (Cresswell, 1994).The same researcher conducted both observations and interviews.

Setting and participants

The fieldwork took place in three maternity departments of Cypruspublic hospitals. Twenty midwives were recruited to the study, using apurposive sampling approach. Ten took part in semi-structured inter-views, and the remainder consented to being observed throughparticipant observation. Midwives were invited to participate if theyhad personal responsibility for caring for women in labour, and hadworked in the unit for more than five years. Less experiencedmidwives and those in general managerial positions were excludedfrom the study, in order to focus attention on the perceptions oftrained and experienced midwives who would be expected to havereached a point where they felt able to act as advocates for normalbirth, and who were likely to be role models for more junior staff.

Ethical considerations

Approval for the study was obtained from the ethics committeeof Middlesex University (where the researcher was registered for apostgraduate degree in midwifery) and also from the Ministry ofHealth in Cyprus (YY.15.6.17.9). As the study included interviewswith midwives and also observation of midwives caring forwomen in labour, it was important to ensure that both midwivesand women were able to participate voluntarily, and that allparticipants were able to provide informed consent. Theresearcher also reflected on her status as a midwifery educator,and the extent to which this might encourage or inhibit midwivesfrom participating in the research. In practice, this backgroundproved beneficial, because the researcher was able to establishrapport with midwives and already had insight into their prac-tices; the research provided an open and trusting forum forparticipants, allowing them to speak freely about their experiencesto a colleague who understood the dilemmas they faced.

Each participant was provided with all the information essentialfor making a decision about whether or not to participate, includingthe input required, and the purpose and benefits of the study.Written consent was obtained prior to the interview, and interviewstook place at a date, time and setting convenient to the participant.During the participant observation phase, when a midwife con-sented to participate, she then sought consent from her own client(s) for the researcher to be present during the shift. Women whoconsented to be observed were assured that their decision toparticipate or not would have no effect on their care and that onlythe researcher collecting the data would be aware of their identity.

In the first phase, data were collected through participantobservation. The researcher observed the activities of a singlemidwife on each field trip, following her through the normalactivities of a shift, which involved being present in rooms whencare was being given to pregnant women or women in labour. Theresearcher made written field notes during the observation, cover-ing conversations, technologies used and any decisions aroundcare that were informed by the outputs of the machines.

Semi-structured interviews

Semi-structured interviews with midwives took place in a pre-booked quiet office in the three hospitals. Two midwives piloted

the interview schedule, and this highlighted the need for somesmall clarifications. Data from the pilot interviews were not usedin the subsequent analysis. Interview topics included perceptionsof factors which facilitated or inhibited midwives' roles as advo-cates for normal childbirth. The interviews lasted from 40 to 60minutes, and were recorded, allowing the researcher to listencarefully, to clarify meaning, and to note occasions when partici-pants appeared to leave some things unsaid.

Data analysis

The field notes were transcribed into more detailed text at theend of each day and once the interviews were recorded andtranscribed verbatim a process of thematic analysis was used(Knale, 1996). Thematic analysis is a method of identifying, analysingand reporting themes within the data (Braun and Clarke, 2006). Athematic chart was constructed and key words and phrases used bythe respondents were entered under the main themes. Anothermidwife-researcher then independently reviewed and crosscheckedthe process of analysis against the transcripts. By this means, aseparate and independent analysis of the data was carried out by tworesearchers, which generated a shared consensus of interpretation(Patton, 2002). This was important because a potential limitation ofany qualitative study is that the researcher's predisposed beliefs maylead to subjective interpretation of data. Trustworthiness of thefindings was also enhanced by a number of mechanisms: findingsfrom participant observation were clarified with midwives who hadbeen observed, and the interview transcripts were shared withparticipants to maximise accuracy (Pretzlik, 1994; Silverman, 2005).

Findings

Of the 20 midwives recruited, 10 had postgraduate midwiferydiplomas and 10 were direct-entry midwives. Respondents wereall experienced clinicians with an average of 22 years in midwiferycare. Following analysis of observation and interview data, fivemain themes emerged. These were Lack of professional recogni-tion; Deficiencies in Basic and Continuing Education; Physiciandominance; Medicalisation of childbirth and Lack of Institutionalsupport. These themes were then compared with existing litera-ture, and confirmation or rebuttal was sought.

The themes were also related to each other, allowing develop-ment of a provisional thematic model using an inductive approach(see Fig. 1). The themes of ‘deficiencies in midwifery education’and ‘lack of professional recognition of midwifery’ were closelyrelated. Cultural acceptance of medical birth and physician dom-inance were barriers to advocacy of normal birth. Each of thesethemes was mediated by institutional support, which referred tolimited evidence of state support through maternity care policyand infrastructure, and a subsequent lack of management supportwithin hospital structures and professional hierarchies.

Lack of professional recognition

Participants felt that because Cypriot midwives have a lack ofprofessional recognition, the women they cared for rarely under-stood the role of midwives as advocates for normal birth. Somebelieved that if midwives were competent and had the rightattitude, they would receive professional recognition:

Respect for normal birth comes only from midwives notdoctors. If midwives as a group are professional and competent,they will be given a more significant role in the multi-professional team. (Midwife 10)

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

Others discussed common and crucial practice issues thatdrove them to advocate normal childbirth. This indicated thatmidwives were engaged in a process of seeking professionalrecognition, and understood the barriers they faced. For example,one midwife discussed lack of choice for women during inductionof labour, and said:

Some obstetricians begin a pitocin infusion [synthetic oxytocininfusion to induce or augment labour], or insert prostin gel[prostaglandin preparation inserted per vagina to inducelabour] without offering adequate information to the women.I disagree with them, but hospital protocols and hierarchyprevent me from reacting or intervening… and then I feel bad… guilty. (Midwife 8)

The researcher observed several occasions where obstetricianstrusted midwives' experience and knowledge and asked midwivesto perform a vaginal examination in order to make certain of theirown assessments, but in some cases obstetricians ignored whatmidwives said and intervened to speed up the course of labour.Professional recognition was thought to depend on acceptance ofmidwives' education and preparation for their role and someparticipants mentioned that they wanted to see improvement inmidwives' basic and continuing education.

Deficiencies in basic and continuing education

Midwives described feeling unprepared to advocate for normalchildbirth. The major education issues identified by midwivesfocused on the quality of basic education, clinical placements,and the lack of exposure to a full range of midwifery practice skills.Almost every respondent in the study mentioned the need formore continuing education programmes which would preparethem to support women to achieve a normal birth, and to beadvocates for women in clinical situations. Some midwives feltthat what is offered to women is medicalised maternity care andothers were frustrated that despite trying, they were not able tosupport normal childbirth. They believed that the main reason forthis is that their basic education did not adequately cover theissues of advocacy, autonomy and empowerment, and continuing

professional educational programmes are insufficient, or not ableto redress this deficiency:

I think that during our training we do not have the opportunityto learn a lot about, advocacy, about midwives' role andpractice in normal birth. (Midwife 7)

Midwives stressed that continuing professional education is anecessity and all of them indicated their desire to undertakecontinuing education programmes in midwifery. Three partici-pants mentioned that continuing education programs would makethem feel empowered and become more competent. Others wereless positive about continuing education, arguing that althoughcourses were very useful, the themes were usually medically ornursing-oriented. More specific seminars on midwifery shouldtake place to help them develop their knowledge and skills asmidwives:

There is some improvement in continuing education pro-grammes. On average, I attend one conference a year but thecontent is mostly about nursing and not midwifery and theopportunity to attend is provided to the same people everytime. Managers do not give the opportunity to all of us toparticipate. (Midwife 6)

Some participants felt that continuing education programmesabout assertiveness would be an important element for empower-ing both women and midwives:

I believe that women during labour and birth should be moreassertive… thus, I offered women sufficient knowledge and Iempowered them to refuse interventions … but this was verydifficult due to physicians dominating the health arena.(Midwife 9)

The other major contextual factor concerned the attitudes andactions of obstetricians.

Physician dominance

Participants highlighted issues relating to the medical domina-tion in the health system as a discouraging factor for advocacy. InCyprus, hospital-based midwives can supervise births with no

Fig. 1. Thematic diagram.

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎4

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

obstetrician present, but obstetricians have the authority to bepresent if they wish and can intervene in the management of thebirth (Hadjigeorgiou et al., 2012). The legacy of a genderedsubordination of female ‘semi-professions’ in relation to male‘classical professions’ is still prevalent in some countries (Weaveret al., 2005). The following example illustrates this theme:

Some midwives do what the doctors say … they do not reacteven when they disagree with them. They do not stand up fortheir rights and women's rights. (Midwife 1)

Most participants believed that medically dominated maternityservices have detrimental effects on both midwives and women.One participant had a particularly strong view and expressed herdissatisfaction as follows:

Midwifery is dying; midwifery is at the edge of chaos; doctorshave the power in Cyprus. (Midwife 2)

Four midwives argued that Cypriot midwives' opinions wereonce respected and recalled that their role previously reflectedthat outlined in the ICM (2011) definition of a midwife. Thisdocument describes a midwife as:

…a responsible and accountable professional who works inpartnership with women to give the necessary support, careand advice during pregnancy, labour and the postpartumperiod, to conduct births on the midwife's own responsibility.

Nowadays, however, obstetricians have the authority andresponsibility and can intervene at any time during labour andbirth. Despite this, not all midwives perceived the role of obste-tricians as an inhibitory factor, or one capable of influencing theirrole in protecting normal childbirth:

It depends on the competence and confidence of the midwifeto stand up to the doctors. (Midwife 5)

The extent to which midwives are able to resist medicalintervention was also used to explain the authoritarianism ofsome doctors in their interactions with midwives, and the degreeto which midwives had the confidence to resist thatauthoritarianism:

I think some doctors will react differently to different mid-wives. If they know it’s a senior midwife who has got lots ofexperience…the doctor would perhaps be more inclined totake a bit more of a back seat and let the midwife direct them.(Midwife 2)

Some midwives mentioned that they often disagree withinterference with the normal process of birth, however they donot feel able to voice their disagreement or challenge medicalcolleagues, but this failure to challenge the doctors may contributeto the ongoing medicalisation of childbirth.

Medicalisation of childbirth

Participants described the medicalisation of childbirth as acrisis affecting mothers, infants, the midwifery profession andwider Cypriot society. When the researcher asked midwives aboutthe main factors that inhibit their role as advocates for normalchildbirth, the majority acknowledged having difficulties in inter-acting properly with women in labour due to the obstetricians'interventions:

Doctors tend to interfere with the natural process…doctorsdisrespect the midwifery philosophy about normal childbirth…the domination of the medical profession is the most difficultbarrier to overcome. (Midwife 1)

Some midwives offered more clarifications to this point byoffering examples from the intra-partum care offered to women.One had the following experience, and described how her clientlost faith in her judgment after intervention by a doctor:

One night I explained to a woman in labour how important it isfor her and her baby to be patient to move around and be calm.A doctor came in laughed and questioned my methods. Thisirritated the woman and she lost her confidence in me. She didnot cooperate with me anymore, she went on to [develop]maternal and fetal distress and she eventually had a caesareansection. (Midwife 4)

Some participants discussed the issue of women asking for acaesarean section without medical indication. Even when mid-wives explained the advantages of normal childbirth, womenwerenot convinced, or did not listen. This led midwives to suggest thatinformation about normal childbirth should be given earlier,during the early stages of pregnancy or perhaps even during highschool education. Some midwives felt despondent about the lowpercentage of normal births in Cyprus and they pointed out thatmight be due to inadequate infrastructure support for their role innormal birth.

Lack of institutional support

Participants felt they were unable to observe, to support andproperly care for women due to time pressures and shortage ofstaff. This could mean that their communication with women wasinadequate at times and might result in unclear information.Quality of information was regarded as a tool to avoid misconcep-tions but could be provided only if the midwives had more timeand more support from managers in the hospital. One intervieweeoffered the following example:

…some doctors, even after we explain to them that we haveexamined the woman and that she needs time, they say thatthey will examine her again because if anything happens theywill be responsible, but in reality they disrespect us and…weare left aside by the doctors and unfortunately no help comesfrom the manager…doctors have full control in the maternityunit in Cyprus. (Midwife 5)

Most of the midwives felt that it was important for them to beacknowledged and respected more by their managers and collea-gues. Another major contextual factor identified by midwives wasthe heavy workload they were often faced with. The greater theworkload of an individual midwife, the less likely it was that shewould act towards her clients in a more facilitative manner. Theinteractions implicit in professional midwifery took up more timethan midwives felt they could afford if they were to fulfil basicstandards of care:

I think it would depend on workload pressures, how manywomen you were looking after, how much time you’ve got tospend, how much rapport you’ve built up with one woman …You know that our ongoing concern is that we require morerespect from the obstetricians and from our supervisors too.Can you imagine they do not realize and they do not listen thatthere is a shortage of staff. (Midwife 4)

Part of this lack of understanding was highlighted by the factthat midwives never had the opportunity to rest during theirwork. One of the midwives explained that if they had more quietperiods, they could pay more attention to women and theirinfants. They could also use the time to discuss issues aboutmidwifery practice and to inform each other about recentevidence.

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

One midwife believed that in order to advocate for her client,she had to oppose an obstetric colleague who was emphasising theimportance of following hospital guidelines, and recalled a situa-tion where she was placed under pressure to increase a syntocinoninfusion:

[I said] Listen, doctor, if you wish to increase syntocinon againstprotocols then do it yourself, but you have to write down whyyou did that… Then she got angry and she left… (Midwife 3)

Advocating for clients could therefore present disadvantagesfor midwives, because it causes conflict with colleagues andmanagers, in a culture where medicalised practice has high statusand value.

Discussion

This study provides evidence of factors that help midwives inCyprus to advocate normal childbirth and barriers that discouragethem from doing so. The research arose from a qualitative studywhich sought to explore perceptions of advocacy amongst mid-wives in Cyprus, a country with a specific political context whichcurrently falls short of supporting normal birth. Strengths of thisstudy are that in-depth data were gathered using both interviewand participant observation methods, affording opportunities fordata comparison and triangulation, and that independent analyseswere undertaken by two experienced qualitative researchers.However, although the experiences of midwives in this settingmay have resonance for midwives in other countries, the researchshould be considered as exploratory, and emerging from theparticular context described rather than having application inother regions.

Midwives can advocate normal childbirth by protecting thenormal birth environment, supporting women's choices, prevent-ing interference with the normal process of birth and throughmeeting women's needs (Carpenter, 1992; Brodie, 2002; Skinner,2003; Anderson, 2003). O'Connor and Kelly (2005) note that theability to advocate is based on sound knowledge and expertise.Similar to the findings of this study, Carpenter (1992) and Skinner(2003) found a positive correlation between education and advo-cacy. Despite the fact that midwives could play a major role inadvocating normal childbirth in Cyprus, the midwifery model ofnormal birth is not fully recognised. Even in public hospitals, therole of midwives is not well-known, and continued presence ofobstetricians at normal births reduces midwives' sense of auton-omy. This may help explain why women remain concerned aboutperceived insufficiencies in midwives' knowledge and skills(Hadjigeorgiou et al., 2012). It seems that in Cyprus, midwivesare not playing a substantial role in health services, and it is likelythat midwives' engagement in policy is hindered by perceivedinsufficiencies in basic midwifery education, and a lack of con-tinuing education programmes for midwives encompassing asser-tiveness, ethics and advocacy.

To address this, midwives should have access to advocacy skillstraining in order to support and empower women to achieve theirown goals and hopes for birth, for their infants and their roles asmothers (Skinner, 2003). Empowering refers to the process wherethe midwife works collaboratively with the mother and providesher with accurate information about childbirth issues and options.This approach creates opportunities for mothers to participate,make decisions and take responsibility for their own care, butsome midwives found themselves in difficulties when theyattempted even that. Midwives identified a need for more inno-vative continuing midwifery education programmes, to addressperceived gaps in advocacy and empowerment skills.

Ingram (1998) reported that health professionals who attendethics courses engage more in advocacy, as they have greaterinfluence and are more effective in resolving ethical conflictswithin the multiprofessional team. A change in continuing mid-wifery education will support the much needed inter-professionalrecognition between midwives and obstetricians. Professionalrecognition will not only benefit midwives but it will also helpto improve the standard of care offered to mothers, infants,families and communities (ICM, 2005a, 2005b).

Professional recognition was thought to depend on acceptanceof midwives' education and preparation for their role. In Cyprus,the key factors motivating midwives to act as advocates are theirdesire to get increased professional recognition and act as auton-omous midwives. This is congruent with Kennedy and Shannon's(2004) findings that midwives should be the primary providers ofcare for healthy pregnant women but they must have the neces-sary skills, knowledge and attitude to be able to undertakethis role.

The main factors which discourage midwives from adopting anadvocacy role are physicians' dominance, medicalisation of child-birth and failure by managers to provide institutional support.Negarandeh et al. (2006) found in their research with Iraniannurses that ‘physicians' dominance’was an important factor whichdiscouraged health professionals from acting as advocates.Furthermore, findings from this study show that when midwiveswork under the authority or direction of obstetricians, theybecome disempowered, leading to an increase in medical inter-vention during childbirth (Kitzinger, 2000, 2005). Medicalisation isclosely related to diminished recognition of midwives as autono-mous professionals and some midwives in this study expressedtheir frustration at feeling unable to challenge medical decisionsduring labour and birth, partly because the women they cared foroften expected birth to be a medical experience and anticipatedinterventions as ‘normal’ practice during birth.

Some midwives seemed to be developing a strategy that soughtto support, encourage and empower themselves and the womenin their care, a strategy that involved listening to women andresponding to their needs (Moscucci, 2003). However; most mid-wives felt that staff shortages prevented them from empoweringwomen. This is consistent with Kirkham's (1990) finding thatmidwives also need support. Acknowledgement, recognition, andrespect from managers positively influenced midwifery care,whereas the opposite had a deleterious effect. Managers did notappear to realise that stress and negative feelings such as guiltwere harmful both for the professionals and for health care andhealth system (Sandall, 1999; Osbourne, 2004). A lack of manage-ment support led some to conclude that in Cyprus, midwifery, as apractice which protects normal birth, is dying.

Conclusion

This article presents midwives' lived experiences advocatingnormal childbirth and strongly suggests that midwifery practice inCyprus faces many challenges. For this reason, provision of con-tinuing professional education programmes on midwifery skillsand normal birth should be given serious consideration. Theimpetus for change must start by helping health professionals,consumers and policy makers understand that birth is a normalphysiological event and therefore does not routinely requiretechnological intervention. In order to be effective advocates,midwives need to be recognised and valued by the public andother health professionals as equal partners within the multi-disciplinary team. They must be empowered and confident inundertaking this role and genuine team work is needed, alongwith the development of a shared philosophy of care and mutual

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎6

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

respect; these factors have been shown to enhance safe and highquality care in other European countries (King's Fund, 2008).Midwives in Cyprus should have more in-depth theoretical teach-ing on advocacy and ethical provision of care, and opportunitiesfor student midwives to have more practice in environments thatpromote and foster normal childbirth. This knowledge, and itsclinical application, should be extended with effective continuingprofessional education programmes focusing on ethics, commu-nication and conflict resolution. Based on this exploratory work,we argue that in Cyprus, the first step towards enhancing theprofile of midwifery is access to continuing professional educationwhich teaches key midwifery skills; this is also likely to be the casein other countries where medical models of birth predominate.

Even though advocacy is widely held to be a very importantelement in maternal health care, it is often lacking from the carethat Cypriot women receive. Therefore, midwives in Cyprus needto challenge the status quo, and find ways to advocate for thewomen and families they care for, to ensure provision of safe,efficient and effective maternity services in Cyprus in the future.

References

Alsop, A., 2002. Continuing Professional Education. Blackwell, London.Anderson, G., 2003. A concept analysis of ‘normal birth’. RCM Evidence-Based

Midwifery 1, 48–54.Arney, W., 1982. Power and Profession of Obstetrics. University of Chicago Press,

Chicago.Barr, H., Low, H., 2012. Interprofessional Education in Pre‐registration Courses. A

CAIPE Guide for Commissioners and Regulators of Education. CAIPE, Fareham.Beech, L.B., 2001. Supporting the mother. Where are the midwife advocates? AIMS

Journal Spring 13 (1), 1–3 ⟨http://www.aims.org.uk/Journal/Vol13No1/midwifeadvocates.htm⟩.

Brodie, P., 2002. Addressing the barriers to midwifery – Australian midwivesspeaking out. Australian Journal of Midwifery 15, 3–4.

Braun, V., Clarke, V., 2006. Using thematic analysis in psychology. QualitativeResearch in Psychology 3, 77–101.

Carpenter, D., 1992. Professional Development Module. P9: advocacy. The "what"and "when" of advocacy. Open learning programme. Part 1. Nursing Times 88,i–viii.

Cresswell, J.W., 1994. Research Design: Qualitative and Quantitative Approaches.Sage, California.

Davis, L., 2000. Keeping birth normal. MIDIRS Midwifery Digest 10, 57–58.Davis-Floyd, R., 1987. The technological model of birth. Journal of American

Folklore 100, 479–495.Davis-Floyd, R., 1994. The technocratic body: American childbirth as cultural

expression. Social Science and Medicine 38, 1125–1140.Davis-Floyd, R., 2001. The technocratic, humanistic and holistic paradigms of

childbirth. International Journal of Gynaecology and Obstetrics 75, 5–23.Davis-Floyd, R., Sargent, C. (Eds.), 1997. University of California Press, Berkeley,

LA and London.Devane, D., Brennan, M., Begley, C., et al., 2010. A systematic review, meta-analysis,

meta-synthesis and economic analysis of midwife-led models of care. RoyalCollege of Midwives, London.

DeVries, R., Benoit, C., Van Teijlingen, E.R., Wrede, S. (Eds.), 2001. Routledge,New York and London.

Downe, S., McCormick, C., Beech, B., 2001. Labour interventions associated withnormal birth. British Journal of Midwifery 9, 602–605.

Downe, S., 2006. Engaging with the concept of unique normality in childbirth.British Journal of Midwifery 1, 352–356.

Enkin, M., Keirse, M., Renfrew, M., Neilson, J., 2000. A Guide to Effective Care inPregnancy and Childbirth. Oxford University, Oxford.

Etuk, M., 2001. Professionalism and accountability. What do they mean inmidwifery practice. The Practising Midwife 4, 28–30.

EURO-PERISTAT with SCPE and EUROCAT, 2013. European Perinatal Health Report.The health and care of pregnant women and babies in Europe in 2010.May 2013. ⟨http://www.europeristat.com/reports/european-perinatal-health-report-2010.html⟩.

Finlay, S., Sandall, J., 2009. “Someone's rooting for you”: continuity, advocacy andstreet-level bureaucracy in UK maternal healthcare. Social Science & Medicine69, 1228–1235.

Friedson, E., 1970. Profession of Medicine: A Study of the Sociology of AppliedKnowledge. Dodd Mead, New York.

Goldberg, L., 2003. In the company of women: enacting autonomy within theperinatal nursing relationship. Nursing Ethics 10, 580–587.

Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopoulos, I., Martenson, L., 2012.Women's perceptions of their right to choose the place of childbirth: aqualitative study. International Journal of Childbirth 2, 230–240.

Hatem, M., Sandall, J., Devane, D., Soltani, H., Gates, S., 2008. Midwife-led versusother models of care for childbearing women. Cochrane Database of Systematic

Reviews 2008, Issue 4. Art. No.: CD004667. http://dx.doi.org/10.1002/14651858.CD004667.pub2.

Homer, C.S.E., Davis, G.K., Brodie, P., et al., 2001. Collaboration in maternity care: arandomized controlled trial comparing community-based continuity of care withstandard hospital care. British Journal of Obstetrics and Gynaecology 108, 16–20.

Homer, C.S.E., Passant, L., Brodie, P.M., et al., 2009. The role of the midwife inAustralia: views of women and midwives. Midwifery 25, 673–681.

Holloway, I., Wheeler, S., 1997. Qualitative Research for Nurses. Blackwell Science,London.

Ingram, R., 1998. The nurse as the patient advocate. ⟨http://www.richard.ingram.nhspeople.net/student/files/advocacy.pdf⟩.

Inhorn, M.C., 2006. Defining women's health: a dozen messages from more than150 ethnographies. Medical Anthropology Quarterly 20, 345–378.

International Confederation of Midwives, 2005a. The philosophy and model ofmidwifery care. ⟨http://www.internationalmidwives.org/assets/uploads/documents/CoreDocuments/CD2005_001%20ENG%20Philosophy%20and%20Model%20of%20Midwifery%20Care.pdf⟩.

International Confederation of Midwives, 2005b. Midwifery: an autonomousprofession. ⟨http://www.internationalmidwives.org/assets/uploads/documents/Position%20Statements%20-%20English/PS2011_011%20ENG%20Midwifery%20an%20Autonomous%20Profession.pdf⟩.

International Confederation of Midwives, 2011. ICM International Definition of theMidwife. ⟨http://www.internationalmidwives.org/assets/uploads/documents/Definition%20of%20the%20Midwife%20-%202011.pdf⟩ (last accessed 31 July2013).

Johanson, R., Newburn, M., Macfarlane, A., 2002. Has the medicalisation of child-birth gone too far? British Medical Journal 324, 892–895.

Kennedy, H., Shannon, M.T., 2004. Keeping birth normal: research findings onmidwifery care during childbirth. Journal of Obstetric, Gynaecological andNeonatal Nursing 33, 554–560.

King's Fund, 2008. Safe Births, Everybody's Business. The King's Fund, London.Kirkham, M., 1990. The culture of midwifery in the National Health Service in

England. Journal of Advanced Nursing 30, 732–739.Kitzinger, S., 2000. Rediscovering Birth. Little, Brown and Co., London.Kitzinger, S., 2005. The Politics of Birth. Elsevier, London.Knale, S., 1996. Interviews, An Introduction to Qualitative Research Interviewing.

Sage Publications, London.Luthy, D.A., Malmgren, J.A., Zingheim, R.W., 2004. Cesarean delivery after elective

induction in nulliparous women: the physician effect. American Journal ofObstetrics and Gynecology 191, 1511–1515.

Mallik, M., 1998. Advocacy in nursing. perceptions and attitudes of the nursing elitein the United Kingdom. Journal of Advanced Nursing 28, 1001–1012.

Mason, J., 1996. Qualitative Researching. Sage, London.McCourt, C., Stevens, T., Sandall, J., Brodie, P., 2006. Working with women:

developing continuity of care in practice. In: Page, L., McCandlish, R. (Eds.),The New Midwifery: Science and Sensitivity in Practice, 2nd edn. ChurchillLivingstone, Netherlands.

McCourt, C., 2006. Supporting choice and control? Communication and interactionbetween midwives and women at the antenatal booking visit. Social Science &Medicine 62, 1307–1318.

Moscucci, O., 2003. Holistic obstetrics: the origins of natural childbirth in Britain.Postgraduate Medical Journal 79, 168–173.

Munro, J., Spiby, H., 2003. Evidence into practice for midwifery-led care: part 3.British Journal of Midwifery 11, 425–428.

Murray, S.F., Elston, M.A., 2005. The promotion of private health insurance andits implications for the social organisation of healthcare: a case study ofprivate sector obstetric practice in Chile. Sociology of Health and Illness 27,701–721.

Negarandeh, R., Oskouie, F., Ahmadi, F., Nikravesh, M., Hallberg, R., 2006. Patientadvocacy: barriers and facilitators. BMC Nursing 5, 3, http://dx.doi.org/10.1186/1472-6955-5-3.

O'Connor, T., Kelly, B., 2005. Bridging the gap: a study of general midwifes'perceptions of patient advocacy in Ireland. Nursing Ethics 12, 453–467.

Odent, M., 2002. The Farmer and the Obstetrician. Free Association Books, London.Odom, J., 2002. The nurse as patient advocate. Journal of PeriAnesthesia Nursing 17,

75–76.Osbourne, A., 2004. A culture of fear: the midwifery perspective. Midwifery Matters

Spring 100, 23–24. ⟨http://www.midwifery.org.uk/?p=123⟩.Patton, M.Q., 2002. Qualitative Research & Evaluation Methods, 3rd edn. Sage

Publications, USA.Polit, D., Beck, C.T., Hungler, B., 2001. Essentials of Nursing Research, 5th edn. J.B.

Lippincott, Philadelphia.Pretzlik, U., 1994. Observational methods and strategies. Nurse Researcher 2, 13–21.Randle, S., 2004. Being an advocate for your clients in the antenatal period.

Midwifery Matters 103, 2–4.Sandall, J., 1999. Team midwifery and burnout in midwives in the UK: practical

lessons from a national study. MIDIRS Midwifery Digest 9, 147–152.Savage, W., Francome, C., 1993. British caesarean rates: have we reached a plateau?

British Journal of Obstetrics and Gynaecology 100, 493–496.Silverman, D., 2005. Doing Qualitative Research, 2nd edn. Sage, London.Simmonds, A.H., 2008. Autonomy and advocacy in perinatal nursing practice.

Nursing Ethics 15, 360–370.Skinner, J., 2003. The midwife in the ‘risk’ society. New Zealand College of

Midwives Journal 28, 4–7.Thompson, J.B., 2004. Human rights framework for midwifery care. Journal of

Midwifery and Women's Health 49, 175–181.

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 7

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i

Timmins, F., McCabe, C., 2005. Nurses' and Midwives' assertive behaviour in theworkplace. Journal of Advanced Nursing 51, 38–40.

Wagner, M., 2001. Fish can’t see water: the need to humanize. Birth 75, 25–37.Walsh, D., 2011. Care in the first stage of labour. In: Macdonald, S., Magill-Cuerden,

J. (Eds.), Mayes' Midwifery, 14th edn. Balliere Tindall, Edinburgh,pp. 483–507. (Chapter 36).

Weaver, E.W., Clark, K.F., Vernon, B.A., 2005. Obstetricians and midwives modusvivendi for current times. Medical Journal of Australia 182, 436–437.

Willard, C., 1996. The nurse's role as patient advocate: obligation or imposition?Journal of Advanced Nursing 24, 60–66.

Williams, D.R., 2006. Preserving vaginal birth: a call to action. Journal of Midwifery& Women's Health 51, 239–241.

World Health Organisation [WHO], 1996. Care in Normal Birth: A Practical Guide.Family and Reproductive Health. WHO, Geneva.

World Health Organisation [WHO], 1999. Care in normal birth: a practical guide.WHO/FRH/MSM/96.24. Available at: ⟨http://www.who.int/rht/documents/MSM96-24/msm9624.htm⟩.

World Health Organisation, 2013. World Health Statistics: demographic and socio-economic statistics Cyprus 2012. Available at: ⟨http://apps.who.int/gho/data/node.main.106?lang=en⟩ (last accessed 31 July 2013).

E. Hadjigeorgiou, K. Coxon / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎8

Please cite this article as: Hadjigeorgiou, E., Coxon, K., In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives'perceptions of their role as advocates for normal childbirth. Midwifery (2013), http://dx.doi.org/10.1016/j.midw.2013.08.009i