This section is organized around themes that were derived from the main research objective. The main themes structuring the findings are the implementation of RMC in daily clinical practice, health facility barriers to practising RMC, and recommendations for improving RMC practices.
Implementation of RMC in daily intrapartum care practices
We explored midwives’ experiences of their daily implementation of RMC in daily intrapartum care. Midwives cited examples of the RMC caregiving practices they have implemented as a result of their participation in the RMC training program as well as indicated the changes they have observed in how they related with childbearing women who were in the healthcare facility for intrapartum care services. We broadly categorized their perceived improvement in their caregiving practices under these subthemes: perceived positive midwife-patient relationship, perceived improvement in midwife’s concern for clients’ overall wellbeing, and recognizing and respecting the autonomy of childbearing women.
Perceived positive midwife-patient relationship
The quotes below are a synopsis of midwives’ accounts of the impact of the RMC training on their practice.
After getting the knowledge, I realized most of the patients, when they come, they already have the misconception ‘nurses are like this, are like that’. But because I had that at the back of my mind, anytime they come, even if they misbehave I talk nicely to them, at the end of the day, we end up creating a very good and cordial relationship. Midwife 006
The training has helped me in managing my clients very well. Now, I do respect their views. Then, any questions they ask, I give them answers. Not like how I used to be before the workshop. I do give them answers and then a hearing ear to their concerns. So it has changed me a lot...Now, I address each patient by her name. Also, I do provide privacy when providing for them, and I don’t use abusive words at them...There were things I was doing before the workshop, now I don’t do (them) anymore. Now, I am cool and calm with the patient and if a patient is trying to provoke me, I will just keep quiet and walk away. Not like at first if you provoke me, I might also say something to you, but now, it has changed. I wouldn’t do that anymore. Midwife 009
Perceived improvement in midwife’s concern for clients’ overall wellbeing
The RMC training has had a positive impact on how midwives communicated and treated the childbearing women in the hospital. The midwives share the following as their experiences with the childbearing women.
Because, like at first, they [the childbearing women] just come, I am only doing my nursing skills, I don’t care about what, at times the patient will go like, the baby is at MBU, so when they come and you ask them ‘how is the baby doing?’ And you want to know more but at first, I will, well, your baby is there and you’ve gone to look for the baby. So I don’t care. You just come, you greet and you go back to your cubicle. I wouldn’t ask further ‘how is the baby’, I wouldn’t; I’ll just sit down. But right now, when they come, I ask them ‘how is the baby?’ and if there is anything, I just reassure them but at first I wasn’t doing that unless maybe the patient opens up. Midwife 003
Right now, we are trying to impact what we learnt at the workshop at the workplace, so we are doing our best to do that. Sometimes too, because you are trying to do that, the patient is able to open up to us, and we are happy after their deliveries; they are free with us because we tried to respect their concerns and all that. So that’s what we’ve been doing...when they come for admission, right from the start, we start the respectful care. We sometimes, ask about their concerns, we try to allay their fears and we address their fears, maybe their misconceptions about this place; some people have some tag about the staff in this hospital, that we are rude and all that, so we try our best to discard all those misconceptions. Yeah. So, we give them respectful care from admission, from the first stage to the second stage, we continue to the third stage until they leave the ward to the post-natal ward. Midwife 010
Recognizing and respecting the autonomy of childbearing women
Some of the midwives mentioned how their participation in the training has helped them to involve childbearing women in caregiving decisions and recognized and respected their views and rights to consent and also to show empathy during care provision. The following quotes elucidate the forgoing point:
…we are supposed to be checking the FH (fundal height) every fifteen (15) minutes, but because of pain, they won’t allow you. But after the training, you have to be by the patient’s side. If I put my hands there (during examination) and she says ‘No’, that ‘I am in pain’ I have to understand…, manage the pain and leave her till when she is ready and decides to be examined, but I explain every procedure to them. But if it was at first, I would have forced the patient. Midwife 003
The trained midwives also report how they involve their client in their care:
Now, we involve them [the women] in the care, and we ask them what they want. You know, sometimes when you are going to give infusion, you tell them we are going to cynto you (to give a Synticinom infusion). Ideally, you have to tell them what to expect when the infusion is on. That the contraction is going to increase and all that. So, you psych their mind before you set up the infusion. Sometimes the patient will tell you ‘me, I don’t want the infusion’ but you just have to try to tell her maybe the importance of that drug that you are going to give her but if she insists that she doesn’t want it, it is her right. So right now, we are trying to involve them in the care that we are giving to them. We don’t want to impose on them and sometimes too, these days, when they get to the second stage, some people will try to just deliver on the floor, deliver at the first stage room. At first, we were insistent that you have to come to the second stage room, you have to do this, you have to lie like this but…after the workshop, we are respecting and accepting their views and choice. We try to make them feel comfortable. Midwife 010
Health facility barriers to practising RMC
We asked the midwives to tell us the conditions acting as barriers to fully implementing RMC practices in their place of work. Their reports on the implementation challenges are organized under these two subthemes: policy and logistic constraint on alternative birthing positions and logistic constraints on ensuring privacy.
Policy and logistic constraints on alternative birthing positions
All the midwives mentioned that the policy and the built environment in the hospital does not support the exploration of alternative birthing positions, and this has made it impossible for the midwives to assist the childbearing women to assume their preferred birthing position.
The alternative birthing positions. It seems because we haven’t gotten the necessary equipment, all our patients have to take the lithotomy position. But when it comes to a patient wanting to step down and walk about a little, it’s been going on well, especially when a patient has no contra-indications of maybe, a rupture, or cord prolapse we allow the patient to walk around. Midwife 005
We use the lithotomy position. The other positions...cannot be used on our wards. When we went for the training, they showed us the beds that they use and other things. And we realized that even if we want to do that ‘we don’t have that kind of bed; the stirrups to support the knee. Midwife 011
Logistic constraints on ensuring privacy
The midwives also mentioned that they lack the logistics to ensure privacy for childbearing women in the open labour ward. They mentioned that the facility has only two screens […], and it makes it difficult to provide intrapartum care for more than two women at a time.
The privacy screens [curtains]…for now, we have two (2) of them outside for patients so sometimes, if you have maybe three (3) labour cases, it means two will be provided with privacy and the others not. Midwife 002
With the ward, providing privacy is one of our biggest challenges…we have fewer screens here. Our screens are not many. You may be using a screen for a patient, the other one too may need a screen but they both can’t have it at the same time so one has to be exposed whilst the other one is screened. So, if the screens are many, and I think each cubicle should have the screen so that the patient will have their privacy. Midwife 009
Midwives’ recommendations for improving RMC practice
From the perspective of the midwives, we sought to understand what they consider to be critical recommendations to promote RMC practices in their place of work. They recommended that logistics for alternative birthing positions and for privacy in the ward should be provided and all midwives and staff of the hospital should be taken through the RMC training program to encourage good practice. The voices of the midwives are captured under each of the subthemes as follows:
Logistics for alternative birthing positions
The recommendations I can make, or we need, are the positions kits required to enable us to implement the other positions we know. Because, just as we’ve been talking about, suppose we get these kits, we may not even revert to the lithotomy position anymore. As far as I am concerned, that is the most important challenge. Midwife 005
Logistics for privacy in the ward
The management should provide, maybe curtains like these (indicating) for all the patients, because when they are lying down, just walking around, others will not see their nakedness and all. I don’t know what they (the administration) are doing about it, but if they are able to provide those curtains, the shower curtain that we can just remove it and wash when there are some stains. Midwife 010
They should provide us with the logistics, and if curtains and other things can be provided...so, now that we have a new facility and there are cubicles, they can provide curtains…for us to ensure a little privacy… Midwife 012
Training for all staff
Yes, add other people to it. So, if maybe, I am suggesting maybe we the participants would be given the opportunity to also, maybe organize workshops for the others and then get them on board. Midwife 001
The management should organize workshops for the whole department so that all our colleagues would be able to get the privilege to go to the workshop because it is very helpful. Midwife 010
All staff from other facilities in the hospital too should have the training. And then, if it becomes very effective, which I know it will be because I have seen the effects, the positive effects myself, then maybe we can forward it to the training schools so that they are also be taught when they are in school. By the time they come out, they have what it takes to give the best of care to their patients. So that will be, and then on the hospital, I think the administration must also be involved. During the training, I didn’t see our director around. But I don’t know whether the next training she can be around or somebody, a representative of the administration, so that they know the importance of what we are learning. Then they can also come out with a policy or something to guide the whole program. It will help with the implementation. Midwife 011