JAN REVIEW PAPER

Expert intrapartum maternity care: a meta-synthesis

Soo Downe1, Louise Simpson2 & Katriona Trafford3

Accepted for publication 2 August 2006

1
Soo Downe BA MSc PhD RM D O W N E S . , S I M P S O N L . & T R A F F O R D K . ( 2 0 0 7 ) Expert intrapartum maternity
Professor of Midwifery Studies care: a meta-synthesis. Journal of Advanced Nursing 57(2), 127–140
University of Central Lancashire, doi: 10.1111/j.1365-2648.2006.04079.x
Preston, UK

2 Abstract
Louise Simpson BA RN RM
Integrated Team Midwife Title. Expert intrapartum maternity care: a meta-synthesis
East Lancashire NHS Trust, Aim. This paper reports a meta-synthesis exploring the accounts of intrapartum
Queens Park Hospital, midwifery skills, practices, beliefs and philosophies given by practitioners working
Blackburn, in the field of intrapartum maternity care who are termed expert, exemplary,
Lancashire, UK excellent or experienced.
3
Background. Expertise in nursing and medicine has been widely debated and
Katriona Trafford RN RM
researched. However, there appear to be few studies of practitioners’ accounts of
Delivery Suite Coordinator
expertise in the context of maternity care. Given current international debates on
East Lancashire NHS Trust,
Queens Park Hospital, the need to promote safe motherhood, and, simultaneously, on the need to reverse
Blackburn, rising rates of routine intrapartum intervention, an examination of the nature of
Lancashire, UK maternity care expertise is timely.
Method. A systematic review and meta-synthesis were undertaken. Twelve
Correspondence to Soo Downe: databases and 50 relevant health and social science journals were searched by hand
e-mail: sdowne@uclan.ac.uk or electronically for papers published in English between 1970 and June 2006, using
predefined search terms, inclusion, exclusion and quality criteria.
Findings. Seven papers met the criteria for this review. Five of these included qual-
ified and licensed midwives, and two included labour ward nurses. Five studies were
undertaken in the USA and two in Sweden. The quality of the included studies was
good. Ten themes were identified by consensus. After discussion, three intersecting
concepts were identified. These were: wisdom, skilled practice and enacted vocation.
Conclusion. The derived concepts provide a possible first step in developing a theory
of expert intrapartum non-physician maternity care. They may also offer more
general insights into aspects of clinical expertise across healthcare groups. Maternity
systems that limit the capacity of expert practitioners to perform within the domains
identified may not deliver optimal care. If further empirical studies verify that the
identified domains maximize effective intrapartum maternity care, education and
maternity care systems will need to be designed to accommodate them.

Keywords: expertise, maternity care, meta-synthesis, midwifery, nursing, qualitative

research, systematic review

wives 2005), and for intrapartum carers in general (Safe

Introduction
Motherhood: Family care international 2002). A recent paper
Basic competencies for intrapartum care have been described has described the attributes of the ‘good’ midwife (Nicholls
for trained midwives (International Confederation of Mid- & Webb 2006). However, there do not appear to be any

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S. Downe et al.

agreed characteristics for non-medical experts in maternity to assess the clinical outcomes of specific aspects of care, such
care settings. This has particular significance in the intrapar- as ‘continuity’, or the predictors of positive outcome, such as
tum period, given the potential for mortality, morbidity and women’s satisfaction with care (see, for example, Nicholls &
for the promotion of maternal and infant wellbeing. In this Webb 2006). We limited our search to qualitative studies as
paper we explore this topic as the first step of a planned we aimed to undertake a very focused review of a specific
programme of work. attribute (‘expertise’) from the perspective of individual
caregivers themselves, and not as predefined by professional
projects, researchers, or policymakers. We believed that this
Background
would permit an interpretation of maternity care expertise
Millions of women give birth every year. While the vast that was as unimpeded as possible by taken-for-granted
majority experience childbirth safely, hundreds of thousands assumptions, as well as offering the potential to reveal any
do not, especially in low-income countries (Betran et al. possible conflicts in perceptions of expertise within and
2005). This has led to international debate about safe between maternity care groups. Given the capacity of
motherhood. Paradoxically, the dominant world-wide risk qualitative designs to capture rich individualized data, we
averse approach to childbirth has been criticized for gener- designed our study as a meta-synthesis.
ating a significant rise in unnecessary intrapartum interven- We did not limit the inclusion criteria to a specific
tions, and, especially, caesarean section (World Health professional group, in recognition that a range of non-
Organisation: Department of Reproductive Health and medical practitioners provide intrapartum care across the
Research 1997). So-called ‘skilled care’ has been proposed world. This was in keeping with our desire to look at the
as a solution to both the safety and the excessive intervention notion of expertise in this area without the assumptions
issues (World Health Organisation: Department of Repro- brought by specific professional projects. During our the-
ductive Health and Research 1997, Safe Motherhood: Family matic analysis, we used the techniques of reciprocal and
care international 2002). While most authorities agree that refutational translation to look for similarities and differences
universal provision of licensed, educated or trained midwives between studies (and thus between professional groups).
would be optimal, economic necessity has led to an accept-
ance that traditional birth attendants (also termed parteras),
Search methods
may be a pragmatic solution in some contexts (Kruske &
Barclay 2004). A perceived need for extra support during The research comprised a systematic review and a meta-
labour has also led to the rise in so-called doulas, who offer synthesis. We included all relevant English Language research
companionship and advocacy to childbearing women, with published between 1970 and June 2006. The decision to
or without formal training (Ballen & Fulcher 2006). commence the search in 1970 was based on the move of
In some jurisdictions, such as the UK, the only practitioners childbirth from the home setting to hospitals. This move
able to take clinical responsibility for labouring women are became marked in high income countries in the 1970s (Arney
medical doctors, and those who have been formally educated 1982, Tew 1998). Hospitalization has influenced maternity
and licensed as midwives (Nursing and Midwifery Council care provision, and the use of birth technologies, across the
2004). In other legislatures, such as the US, there is a plurality world. For example, caesarean section is now the standard
of provision (American College of Nurse Midwives (ACNM) mode of birth for some communities in Brazil (McCallum
2005, MANA 2006). We were interested in exploring expert 2005). We concluded that this changing context of maternity
non-medical intrapartum care in the context of this range of care would limit the applicability of studies published before
provision. 1970.
There is a substantial body of literature around expertise The research question was:
for medical practitioners (Custers et al. 1996, Eraut & Du
What accounts of intrapartum midwifery skills, practices, beliefs and
Boulay 2001) and for nurses (Benner 1984, Benner et al.
philosophies are given by practitioners working in the field of
1996, Price & Price 1997). However, we could not locate any
maternity care who are termed expert, exemplary, excellent or
authoritative research-based texts on non-medical intrapar-
experienced in intrapartum maternity care
tum expertise. Our aim, therefore, was to examine this topic
through studies of intrapartum practitioners who were In the text below we have used the term ‘beyond the ordinary’
termed expert, exemplary, excellent, or experienced. as a pragmatic shorthand for ‘expertise’, ‘exemplary’ ‘excel-
Although we knew of many quantitative studies exploring lent’ and ‘experienced’. Our definitions and exclusion criteria
optimal maternity care practices, they tended to be designed are given in Table 1.

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JAN: REVIEW PAPER Expert intrapartum maternity care

Table 1 Definitions and exclusion criteria

Definitions

Term Explanation

Qualified midwife Qualified and licensed midwives

Midwifery student Students studying courses that meet the criteria for licensing as midwives
Nurse Qualified and licensed nurses who work in an intrapartum setting but who are not
qualified and licensed as midwives
Nurse-midwife Qualified and licensed nurses who are also qualified and licensed as midwives
Lay midwife Experienced clinical practitioners who practice intrapartum care, but who are
not formally licensed as midwives.
Traditional birth Experienced local women who practice intrapartum care, but who
attendant, partera, dai are not formally licensed as midwives or nurses
Doula Labour supporters who are not trained or licensed in clinical midwifery practice,
but who may have received specific formal training in techniques of labour support
Beyond the ordinary A high level of knowledge or skill: studies where any of the following terms are used to
describe the participants: expert, experienced, exemplary
Exclusion criteria • Opinion papers
• Research that only resulted in quantitative data
• Participants not maternity care practitioners according to the definitions above
• Participants not identified as ‘beyond the ordinary’ according to the definition given above
• Papers focused a priori on specific aspects (such as intuition) or narrow areas of practice
(such as using the ventouse, or undertaking episiotomy)
• Studies with inadequate information to establish the quality of the research.

We searched 12 databases, hand searched five journals and quality criteria for including studies were based on the
regularly scrutinized the contents pages of a further 45 Critical Appraisal Skills Programme (CASP 2002) and on
relevant health and social science journals (see Box 1 for Walsh and Downe (2006).
details). We contacted relevant e-groups and experts for grey
literature. A full list of the initial and final search terms used,
The reviewing process
and resources searched, is available from the authors. The
The process of reviewing was highly iterative and revisionist
Box 1 Sources for search (Walsh & Downe 2005). It was closely aligned to qualitative
constructionist epistemologies.
Databases/search engines
CINAHL
Allied and Complementary Medicine Stage 1. Title, abstract and full text review
British Nursing Index Two members of the team (LS, KT) independently undertook
EMBASE the search. The total hits amounted to over 15,000. For the
MEDLINE overwhelming majority of these papers the titles indicated
Ovid MyJournals
that they were either not relevant to the study, were not
AMED
BIDS qualitative research papers, or did not include participants
ASSIA meeting our definition of ‘beyond the ordinary’. These titles
ProQuest were excluded. Where this was not clear, the abstract was
Midwives Information and Resource Service (MIDIRS) reviewed. After extensive discussion between all three au-
National Research Register
thors, full text papers were obtained for seventeen studies
Journals handsearched
British Journal of Midwifery
(Table 2). They were initially reviewed blind to each other by
Social Science & Medicine LS and KT. Differences in opinion were mediated by SD. The
Midwifery quality of the remaining papers was blind assessed using the
Birth Critical Appraisal Skills Programme criteria (CASP 2002).
Journal of Advanced Nursing This covers three areas, namely rigour, credibility, and rele-
Contents pages of 45 other relevant health and sociology journals
vance, using ten prompt questions. Ten papers were excluded
were searched regularly via Zetoc (details available from the lead at this stage. The primary reason for exclusion is given in
author). Table 2.

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S. Downe et al.

Table 2 Studies identified after abstract

Final
review: final inclusion and exclusion
Author, date decision Reason for exclusion

Davis-Floyd and Davis (1997) Excluded No indication that the participants were ‘experts’
Guiver (2003) Excluded No indication that the participants were ‘experts’
Shallow (1999) Excluded No indication that the participants were ‘experts’
Konstantiniuk et al. (2002) Excluded Only quantitative data
Stamp (1997) Excluded Only quantitative data
Patrick (2002) Excluded Only quantitative data
Alexander et al. (2002) Excluded Specific to ventouse practitioners
Butterworth and Bishop (1995) Excluded Only 13% of participants maternity
care practitioners
Kennedy et al. (2003) Excluded Meta-synthesis of American studies (one relevant
paper included in this review)
Sookhoo and Biott (2002) Excluded Insufficient data to assess quality
Sleutel (2000) Included
Kennedy (2000) Included
Berg and Dahlberg (2001) Included
Lundgren and Dahlberg (2002) Included
Kennedy (2002) Included
James et al. (2003) Included
Kennedy (2004) Included

Stage 2. Detailed quality review of included studies paper contains a report of a different study, a sub-set of
A detailed quality assessment based on the checklist of Walsh the participants appears to overlap all three studies. Two
and Downe (2006) was undertaken for the remaining seven studies were from Sweden, both with the same second
studies. This assesses the appropriateness and coherence of author but reporting different studies, with no apparent
the study scope and purpose, design, sampling strategy, overlap of participants. Participants included nurses, nurse–
analysis, interpretation, researcher reflexivity, ethical midwives and midwives. The quality was generally good,
dimensions, relevance and transferability. A summary score with some weaknesses in the use of techniques to ensure
was then allocated (see Table 3 for details). A full account of the transparency of the analysis, and in reflexive account-
the quality assessment of each study is available from the ing.
authors.

Findings
Analysis
We initially identified 13 themes from the data (see Table 4).
The analysis involved the following stages: compare and After discussion, we agreed that the data separated out under
contrast metaphors, phrases, ideas, concepts, relations ‘connection’ and ‘companionship’ was of a similar order, and
and themes in the original texts; undertake reciprocal and these were combined into one theme (connected companion-
refutational translations to establish how far the themes ship). We also noted that, as well as the original value of
arising from the included studies were similar, or different; ‘trust’ there were values relating to belief (in normal birth,
then synthesize the themes arising from the preceding steps and in women’s bodies), and to courage. The original theme
(Noblit & Hare 1988, Walsh & Downe 2005). For each step, of trust was therefore expanded into a theme of ‘value’. We
we undertook the analysis separately. We agreed on the final noted that issues of role change, profession, and of accom-
analysis by consensus. modation to adverse external forces were more about process
and context than expertise. We combined these into a parallel
concept termed ‘reaction to the context of childbirth’. The 10
Results
themes remaining in the analysis were then subject to
synthesis. Three overarching domains were identified: wis-
Characteristics and quality of included papers
dom, skilled practice and enacted vocation. Nurses, nurse–
Five of the included studies were undertaken in the USA. midwives and midwives were represented in each of these
Three of these were by the same author. Although each domains.

130  2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd
 Table 3 Characteristics and quality of included studies

Sleutel 2000, Kennedy 2000, Kennedy 2002, Kennedy 2004, James et al. 2003, Berg & Dahlberg Lundgren & Dahlberg
Criteria USA USA USA USA USA 2001, Sweden 2002, Sweden

Scope and To describe labour sup- ‘to describe exemplary Study undertaken ‘as a ‘to expand knowledge ‘to examine how expert To describe how midwives To describe midwives
purpose port techniques and midwifery practice means of corrobor- on the processes and perinatal nur- experience the care of experience of the
strategies to enhance Extensive theoretical lit- ating’ findings from outcomes of ses…view their role in women who are at high encounter with
labour progress and erature cited. Kennedy 2000 midwifery care’ caring for mothers obstetric risk or who women and their pain
JAN: REVIEW PAPER

prevent caesarean Very little literature Both directly relevant during labour and have an obstetric during childbirth
births cited and theoretical birth’ complication… Large range of relevant
Fair links with literature literature cited Some directly relevant Range of directly relevant literature cited
literature cited and theoretical literature
cited
Design, Interpretive Theoretical framework ‘qualitative’ Theoretical framework Theoretical framework Phenomenology Phenomenology
methods interactionism feminist, and emanci- Videotaped interviews not explicit not explicit Tape recorded interviews Tape recorded
Termed a ‘pilot study’. patory. Videotaped interviews Tape recorded focus interviews
Observation and Delphi study groups
interview
Sampling One labour and delivery Midwife participants: 11 ‘expert’ midwives 14 midwives (and 4 4 ‘large mid western’ Four hospitals where the ‘Experienced’ midwives
strategy ward with 70–100 Midwives who had been from original 64 in the recipients of care, not hospitals (births per care of women at high (n ¼ 9) in two
Participants births/month (Oct honoured for Delphi study included in this annum 2800–6500). obstetric risk was dif- hospital settings in
1998–March 1999). excellence by the (Kennedy 2000). Not review). 11 from Selected because ferentiated from care of Sweden. Not clear
Not clear why hospital ACNM clear why these 11 original Delphi study nurse-managed labour other women why these settings
was selected. CNM’s nominated as were selected. (Kennedy 2000). It is was the practice 10 midwives (of 11 were chosen.
One participant ‘exemplary’ (expert, Age range 49–62; years not clear if these model. invited) with at least Participants chosen as
interviewed: criteria: and excellence, also in practice 6–29. 64% participants were 8 focus groups 54 nur- 5 years experience, and ‘experienced’ by the
min 3 years used in some places in masters level educa- those in Kennedy ses: ‘at least 5 years recognized as being head midwife at both
experience labour and the text) by: tion. Most worked in 2002. 3 midwives intrapartum experi- ‘highly skilled sites.
delivery, graduate or – leadership of ACNM hospital: 2 attended ‘theoretically sampled ence’ clinicians’. Demographics: age

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd

equiv level, ‘nurturing, and home births, and 2 based on emerging Demographics: range of Demographics: age range range 38–52,
caring demeanour’ – a stratified random worked in birth findings’ years of experience 5– 41–52, 9–29 years 12–28 years
(‘expert’) sample of 62 nurse centres. Years in practice 38 Hospitals: rates of midwifery practice midwifery practice.
Demographics not given midwifery service 6–40. Practiced in ‘ a intervention higher (5–8 years ‘high risk’).
directors across the US variety of settings’. than in US national
Midwives nominated by statistics
the leadership of
MANA. n ¼ 64/142
nominations for first
round, 52 completed
all three rounds)
Participants were
distributed across 6
ACNM regions of US,
1 from Canada. Years
experience 1–45. Age
range 39–73. 90%
Caucasian. 73%
college graduates,
70Æ5% masters
degrees. A variety of
birth settings
represented. Range of
births 3–184 annually
Expert intrapartum maternity care

131
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S. Downe et al.

Table 3 (Continued)

Sleutel 2000, Kennedy 2000, Kennedy 2002, Kennedy 2004, James et al. 2003, Berg & Dahlberg Lundgren & Dahlberg
Criteria USA USA USA USA USA 2001, Sweden 2002, Sweden

Analytic strat- Emergent, iterative Content analysis, using Emergent, iterative, Narrative analysis using Inductive coding & Analysis used method Analysis used method
egy Examples given of NUD*IST, and using constant Atlas ti, and based on thematic methods of described by Giorgi described by Dahlberg
how analysis evolved, measures of central comparative analysis, codes and themes. analysis 1997. This involved et al. 2001: reading
large amounts of data tendency using SPSS. based on grounded Findings triangulated Findings triangulated the identification of and re-reading text,
provided. Data triangulated theory with Delphi findings between the four meaning units, identifying ‘meaning
Triangulation between between qualitative Not clear if saturation The authors state that centres transforming the units’, unpacking the
participants’ account data and ranking was reached, or if they reached data Data saturation and a meaning units, meaning of the text,
and observational statements. disconfirming data saturation. It is not search for synthesizing and and relating the
data Not clear if saturation were sought and clear if disconfirming disconfirming data not summarizing, and the meaning units to each
Some evidence of was reached, or if accommodated. data were sought and noted. formulation of a other. The ‘subjects
saturation (though disconfirming data No mention of accommodated Analysis undertaken by general structure of naive description’ was
only one participant): were sought and participant or external Analysis undertaken research team and the phenomenon. then transformed into
evidence of accounting accommodated. verification of findings by all four authors ‘two independent’ Triangulation not ‘language meaningful
for disconfirming On-going analysis collaboratively. The researchers.. apparently part of the for midwifery’.
data. verified with a final synthesis was Findings reviewed by 3 method. Triangulation not
Participant and external research jury. also discussed with focus group Not clear if saturation apparently part of the
expert verification of experienced participants. or disconfirming data method.
findings noted researchers outside the sought. Not clear if saturation
research team. The No mention of or disconfirming data
process is fully participant or external sought.
explained verification of findings No mention of
(although the first participant or external
author notes that ‘the verification of findings
other researcher was (although the authors
not a midwife which state ‘the interviews
contributes to were ‘primarily’
objectivity’. analysed by the
interviewer).

Quality rating B A B A B B B

Key to quality rating: A, no or few flaws. The study credibility, transferability, dependability, and confirmability33 is high; B, some flaws, unlikely to affect the credibility, transferability, dependability, and/or confirmability
of the study; C, some flaws which may affect the credibility, transferability, dependability, and/or confirmability of the study; D, significant flaws which are very likely to affect the credibility, transferability, dependability,
and/or confirmability of the study.

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JAN: REVIEW PAPER Expert intrapartum maternity care

Table 4 Emerging themes and concepts

Themes, first iteration Themes, final iteration Core concept Relevant papers

Education Education through training Wisdom Kennedy (2000)

Experience and experience Berg and Dahlberg (2001)
Knowledge Knowledge James et al. (2003)
Competence Reflexive competence Skilled practice Sleutel (2000)
Confidence Confidence Kennedy (2000)
Judgement Judgement Berg and Dahlberg (2001)
Skills Technical skills Kennedy (2002)
Lundgren and Dahlberg (2002)
James et al. (2003)
Kennedy (2004)
Trust Values (belief, courage, trust) Enacted vocation Sleutel (2000)
Intuition Intuition Kennedy (2000)
Connection/ Connected companionship Berg and Dahlberg (2001)
companionship Kennedy (2002)
Lundgren and Dahlberg (2002)
Kennedy (2004)
James et al. (2003)
Role changes Role changes Parallel concept: Reaction Sleutel (2000)
‘Profession’ ‘Profession’ to context of childbirth Kennedy (2000)
’ironic intervention’ Berg and Dahlberg (2001)
James et al. (2003)

Summary of domains and themes I have to hear what she is saying. I have to hear, I have to feel, absorb
what it is she wants, what she’s afraid of, what she is going
Wisdom
through…I can feel it in the air, fell it in the vibrations, you can see it
Education through training and experience. There was very
in her body language, hear how she breathes, speaks (p. 263)
little reference in the studies to formal midwifery or
maternity care education. It seemed to be taken for granted James et al. (2003) note that labour care nurses displayed ‘the
as a core requirement. The more important capacity intuitive nature of nursing care (p. 818)’. This was bound up
seemed to be the ability to reflect on and integrate in an intimate knowing about the process of labour built up
both experiential and formal education into a basis for by years of experience, and underpinned by ‘deep under-
on-going knowledge development. James et al. (2003) term standing’. Knowledge was not a superficial consequence of
this process ‘the ability to use the past in the present’ (p. book learning, but a much more deeply felt and expressed
818). consequence of consciously living with and learning from
The quality and diversity of education and experience, birth:
coupled with the reflective capacity of the practitioner,
Expert nurses were open to rethinking a situation, emphasizing the
enabled the development of expert practice. Further, expert
importance of constantly assessing and reassessing a woman’s labour.
learning encompassed a kind of intellectual curiosity (Ken-
An expert nurse was not threatened when her planned interventions
nedy 2000), a continuing search for more educational
proved ineffective, or required modification (p. 819)
opportunities, and an intelligent questioning of the taken
for granted. This illustrates an acceptance of uncertainty, and awareness
that there are no ‘preset patterns’ in birth. Eraut (1994) has
Knowledge. Berg and Dahlberg (2001) note the expert’s hypothesized that there are two types of professional know-
ability to accommodate both embodied and theoretical ledge. Type A (public knowledge) is subject to external
knowledge. They refer to ‘sensitive knowledge’ (p. 263) and quality control and built into educational programmes,
‘sensitivity for the spontaneous’ (p. 261). These phrases examinations and qualifications. It is about knowing that,
express the capacity of the midwives in their study to not knowing how. Type B (professional personal knowledge)
demonstrate ‘a developed ability to use ones senses’. As one is a synthesis of both knowing that, and knowing how. This
of their respondents says: appears to be expressed in the papers included in this section.

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S. Downe et al.

Synthesis. The two themes in this section seemed to coalesce of the births they attended: paradoxically, in being the
into something that was beyond intellectual knowledge, experts, they no longer needed to claim their expertise. As
repeated years of experience, or book-learning education. James et al. (2003) state, they were able to ‘let the woman
This led us to the concept of wisdom. Although some nursing own the labour’. Lundgren and Dahlberg (2002) express
theorists (Lauder 1994, Litchfield 1999), and alternative something similar when they comment that the practitioners
midwifery publications (Tritten 1992) have paid attention to in their study ‘met the woman as a unique individual in an
wisdom, it appears to have fallen out of favour recently. The open-minded way’. However, they were also highly respon-
following quote summarizes the way in which we want to use sive to pathology when necessary, ‘seizing the women’ when
the term: they found that labour exceeded their ability to cope.

Wisdom is a state of the human mind characterized by profound

Confidence. A person who is objectively competent may lack
understanding and deep insight. It is often, but not necessarily,
confidence in their abilities, and an over-confident person
accompanied by extensive formal knowledge. Unschooled people can
may over estimate their capacities. Generally, however,
acquire wisdom, and wise people can be found among carpenters,
confidence and competence did co-exist in this review.
fishermen, or housewives. Wherever it exists, wisdom shows itself as
Kennedy (2000) noted that the midwives in her study had
a perception of the relativity and relationships among things. It is an
the confidence to make decisive decisions. In a later study
awareness of wholeness that does not lose sight of particularity or
(Kennedy 2002), there is a rather different construction of
concreteness, or of the intricacies of interrelationships. (Meeker
confidence, termed ‘the art of doing ‘nothing’ well’. This
1981)
phrase expresses a confidence to not act. The contingent
nature of acting or not acting echoes the points made above
Skilled practice
about reflexive competence. As James and colleagues state:
Reflexive competence. The classic analysis of Benner propo-
ses that the route to expertise starts as a novice, and The confident nurse stepped away from the technology and towards
progresses through the competence and proficiency (Benner the woman. (James et al. 2003, p. 819)
1984). However, controversy surrounds the concept of
Berg and Dahlberg (2001) note that the midwives in their
competence (Worth-Butler et al. 1995). At the basic level,
study undertook ‘balancing’ in a number of areas, including
this may mean only the performance of routine clinical skills
the facilitation of mutual confidence with the medical staff.
according to standard procedures and guidelines. In contrast,
While this appears to be a benign observation, in some cases
the skills noted in Kennedy’s (2000, 2002) studies suggest
friction between different philosophies of labour led to
dynamism and contingency:
practitioners acting in ways which did not reflect their beliefs
When you bump the boundaries (of normal) my job is to gently guide about birth, and which potentially undermined their confid-
you back…I was a guest, and I was invited to be an expert, but only if ence in their particular expertise (Sleutel 2000, Berg &
they needed me to be one. (Kennedy 2002, p. 1759) Dahlberg 2001). These aspects are explored in more detail
below under ‘Reaction to context of childbirth’.
This speaks of a reflexive competence that can deal with
uncertainties and rapid changes in labour, and which is not
Judgement. From a risk-aversive perspective, the more com-
dependent on standard protocols, and routine techniques.
plex a judgment needs to be, the more likely it is an error will
Kennedy suggests that the expert midwife ‘orchestrates
be made. The main justification for the production of
labour’, and ‘creates/manoeuvres the birth space for women’
protocols, guidelines and nomograms is to minimize these
(Kennedy et al. 2004). This is an active process that provides
risks. However, an adverse consequence of this increasing
a kind of guardianship. It creates what Walters and Kirkham
standardization is a restriction of creativity, and a decreased
(1997) have termed a ‘safe space in which the mother is the
capacity to respond to and innovate in novel situations. Eraut
main actor’.
and Du Boulay (2001) note that professional experts often
All of the authors of the studies included in our meta-
have to take decisions in situations that are ill-structured,
synthesis noted that the experts in their studies needed to be
uncertain, shifting, subject to high stakes, involve multiple
skilled in clinical techniques. However, they also seemed to
players, and that are contextualized by time stress and
possess anticipatory and preventative competence. They
organizational goals and norms. Arguably, labour consis-
predicted likely events, both in the labouring women, and
tently demonstrates these characteristics. Expert maternity
in the surrounding environment, and worked with these
care practitioners therefore have to negotiate both the
predictions to optimize outcomes. This allowed them to let go

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uncertainty and complexity of the actual process of labour as practice was made up of reflexive competence, confidence,
well as negotiating the organizational and inter-professional judgement and the capacity to use technical skills. Eraut and
hurdles that accompany maternity care in the twenty-first Du Boulay (2001) note that theorists working in the area of
century. This was particularly evident in the study of Sleutel, ‘naturalistic decision-making’ have moved from a context-
where the key concept was that: independent position of decision-making as a purely psycho-
logical process, towards one of context-dependence. For
Intrapartum nursing care reflected both a medical model of control-
example, Lipshitz (1993) notes that decision-making is
ling and hastening birth, as well as a supportive, nuturing and
influenced by the different contexts in which the decision is
empowering model of practice that used independence, clinical
made; the practitioners assessment of relevance in the par-
judgements, and advocacy. (Sleutel 2000, p. 38).
ticular situation; and use of complex mental imagery (such as
In two of the studies, judgement is both a result of independ- illness scripts) as well as analytical reasoning. It may be that
ent decisions by the practitioners, and of accommodating this is the kind of skill base used by expert maternity care
external forces, such as ‘dealing with the pressures to speed up practitioners. Indeed, we would theorize from our findings
the labour process’ (James et al. 2003), or of using one set of that some practitioners may use ‘salutogenic’ (described as
interventions to avoid more invasive procedures (Sleutel wellbeing by Downe and McCourt (2004) scripts, as well as
2000). Where practitioners were free to make judgements ‘illness’ scripts. In particular, this may explain some of the
on the basis of labour itself, these decisions were made along a data in Berg and Dahlberg (2001) in the context of women at
spectrum that was conceptualized by Lundgren and Dahlberg high risk. This theory remains to be tested in future research.
(2002) as ‘waiting for the woman’ at one extreme, and ‘seizing The subtle and complex activities that were geared around
the woman’ at the other. The expertise lay in balancing these keeping birth normal included hands on-high touch tech-
two extremes, and in setting up and judging the labour niques, the orchestration observed by Kennedy (2002), and
(termed’orchestrating’ by Kennedy (2002) so that overt the enactment of the ‘sensitive knowledge’ noted (Berg &
decision-making that interrupted the flow of the birth only Dahlberg 2001). The drive seemed to be ‘the struggle for the
needed to happen when pathology was unavoidable. natural process’ even in the context of women at high risk
Crucially, the use of expert skills was framed by an (Berg & Dahlberg 2001).
acceptance of accountability for the judgments made
(Kennedy 2002). Enacted vocation
Values (belief, trust, courage). Belief includes both belief in
Clinical skills. Skills encompassed both technical capacity, women’s capacity to give birth, and in the process of
and emotional intelligence. Technical skills were evident in childbirth as fundamentally physiological. This was
both the use of equipment and emergency procedures, and, expressed as ‘following the mother’s body’ (Sleutel 2000),
more subtly, in keeping birth physiological (Sleutel 2000, ‘belief in women’s bodies’ (James et al. (2003), and ‘belief
Kennedy 2002). James et al. (2003) note that practitioners that women’s body was capable’ (Lundgren & Dahlberg
could call upon a ‘bag of tricks’. These included ‘technolo- 2002). For the women at high risk in Berg and Dahlberg’s
gical skills and judgment, and ‘hands on, high touch study, the authors noted the midwives’ ‘support of the natural
supportive care techniques’. While touch can be positive or processes, particularly…in apparently hopeless cases…’. This
negative (Kitzinger 1997, El-Nemer et al. 2005), in James and contrasts strongly with the critique of technological child-
colleagues study it was clearly framed as supportive, and birth processes expressed by Emily Martin (2001), who
protective of physiological processes. Clinical skills included argues that modernist technocratic childbirth systems treat
observation, assessment, and positioning of the woman women’s bodies as if they are faulty and need fixing.
(Sleutel 2000), and reading women’s bodies without resorting Trust was both a consequence and a cause of the strong
to external measurement and machine recordings (Lundgren belief in normality. A number of the authors talk about the
& Dahlberg 2002). Emotionally supportive skills included mutuality and reciprocity of the trust between labouring
warmth, nurturing, gentleness, kindness, caring, and positive women and midwives (Berg & Dahlberg 2001, Lundgren &
encouragement (Kennedy 2000, Sleutel 2000, Berg & Dahl- Dahlberg 2002, Kennedy et al. 2004). As Kennedy and
berg 2001, Lundgren & Dahlberg 2002, James et al. 2003). colleagues note:

the mutuality between the midwife and the women is foundational,

Synthesis. While is logical to assume that an expert is skilled
leading to an engaged presence by the midwife (Kennedy et al. 2004,
in the area of their expertise, the nature of ‘skill’ may be less
p. 17).
obvious. Our reading of the texts we located is that skilled

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S. Downe et al.

This serves as a virtuous circle, reinforcing trust and belief in midwife in Kennedy’s studies (Kennedy 2002, Kennedy et al.
the midwife, and empowering the midwife to offer it back to 2004). Benner describes the process of ‘prescencing’ as being
the next labouring woman. As Davis-Floyd and Davis (1997) with, as opposed to doing for, a patient (Benner 1984, p. 57).
note: ‘Mothers and midwives mirror one another – it’s a Kennedy emphasizes this interpersonal connectivity by using
dance – the woman has to trust the midwife and the midwife term ‘engaged presence’. This describes more than just being
has to trust her woman for that bouncing back’ (p. 337). present in the room with a labouring woman. It is the essence
The final value we located was courage. Berg and Dahlberg of a relationship or ‘connection’ the expert midwife has with
(2001) comment that midwives needed to be courageous to the woman. Sleutel (2000) sees it as supportive, nurturing
act in accordance with intuition, especially in the context of and empowering, James et al. (2003) and Berg and Dahlberg
the women at high risk in their study. Similarly, James et al. (2001) both talk of ‘being attuned’, and Lundgrun and
(2003) observed that, in order to be an advocate for Dahlberg (2002) of ‘being an anchored companion’. These
labouring women in a setting where there were pressures to notions of companionship are accompanied by qualities that
intervene, labour ward nurses had to ‘have the guts to do express a relationship of profound caring. This is far removed
what you believe to be right and in the best interest of the from objective professionalism. It is also more than a
woman and her baby’ (p. 820). Beyond the everyday need for maternalistic relationship, in which the midwife ‘does for’
courage in decision-making, Kennedy et al. (2004) notes that the labouring woman. In order to be connected the midwife
midwives had a ‘commitment to revolutionalising systems must ‘know and understand’ the woman as a unique indi-
where necessary’. Courage also extended to an acceptance of vidual (Kennedy 2000), working with her as a partner in the
responsibility and accountability for the consequences of birth process, where both midwives and woman are
actions undertaken. co-responsible (Lundgren & Dahlberg 2002).

Intuition. One respondent in Kennedy’s first study commen- Synthesis. The notion of vocation has fallen from favour as
ted that an expert midwife has ‘an uncanny knowing when to skilled practitioners have pursued the aim of professional
step in and when to let be’ (Kennedy 2000, p. 9). The gestalt credibility. However, in gaining the status of profession, with
capacity for intuition is also noted in other reports (Berg & the consequent super-valuing of higher level education, the
Dahlberg 2001, Lundgren & Dahlberg 2002, James et al. qualities and values of vocation may well have become
2003). Benner deconstructed the concept of intuition in overlooked. As the practitioners in our review became more
nursing practice, and concluded that ‘the expert performer no expert, they appeared to (re)value and to express qualities
longer relies on an analytic principle (rule, guideline, maxim) such as trust, belief and courage, to be more willing to act on
to connect her or his understanding of the situation to an intuitive gestalt insights, and to prioritize connected relation-
appropriate action. The expert nurse…now has an intuitive ships over displays of technical brilliance. This did not,
grasp of each situation’ (Benner 1984, p. 31–32). Benner however, result in denial of responsibility. On the contrary, in
expressly refrains from seeing this process as mysterious. For some of the accounts, the enactment of vocation led these
her, intuitive expertise is built on the knowledge, under- experts to move outside of and beyond normative childbirth
standing and experience that precedes the intuitive leap. For practices, and so to become more exposed to critique.
Davis-Floyd and Davis (1997), learning to trust intuition is Equally, while stepping back and doing less may seem to be
an ongoing process, with intuitive thinking dominating as less skilled than stepping in and doing more, Kennedy
expertise increases. However, arguably, an expert midwife succinctly describes the expertise of enacted vocation in this
cannot rely on intuition alone. As Kennedy notes: way:

The midwives’ discussion on intuition centred on a concern that the working to create an environment of calm, trusting in the normal
exemplary midwife cannot rely on this alone in clinical practice. It birth process, and being present during labour may appear to be
does not exempt the midwife from expert knowledge or clinical nothing, or inconsequential, but, in reality, it is likely to be very
experience…‘the intuitive knowledge backs up the findings as it significant. (Kennedy 2002, p. 1760)
provides the practitioner with a motive to investigate the cause’.
(Kennedy 2000, p. 10)
Parallel theme: Reaction to the context of childbirth

Connected companionship. Being ‘present’ for the woman Role change, professional conflict and ‘ironic intervention’.
during the birth process but not actually ‘doing’ anything We have separated out this theme, as it is less to do with
physical is seen as a fundamental component of the expert expertise per se than with the way expert practice is

136  2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd
JAN: REVIEW PAPER Expert intrapartum maternity care

moderated, or even distorted, by context. This was most officials. However, each of these groups would also have only
strongly evidenced in Sleutel’s (2000) analysis. Sleutel’s key given a partial and particular view on maternity care
concept is that ‘intrapartum nursing care reflected both a expertise. The exclusion of quantitative studies may have
medical model of controlling and hastening birth, as well as a limited the scope of our work, as there were far more of these
supportive, nurturing and empowering model’ (p. 38). This studies in the general area of maternity care provision than
paradox was expressed by the apparently oppositional con- there were of qualitative studies. However, we believe the
cepts of ‘following the mother’s body’ and ‘hastening and view we present stands on its merits as our particular
controlling labour’. Sleutel notes that this led to practitioners construct of the rich and in-depth accounts of a particular set
using interventions they did not really support in order to of practitioners working in the field of intrapartum maternity
avoid the (to the practitioners) larger risk of caesarean section care who are practising in ways deemed ‘expert, exemplary,
for women who would otherwise have transgressed rigid excellent, or experienced’. Our interpretation of the data may
technocratic labour norms. A similar practice was noted in or may not have resonance for others in the field of maternity
Annandale’s study of a birth centre (Annendale 1988), and it care, or for healthcare practitioners working in other fields.
is the term Annandale coined to describe this situation that
we have used here, namely ‘ironic intervention’. The risk here
Implications of findings
is the disruption of the virtuous circle of trust and belief,
which we discussed above, and a downward spiralling of the The findings of this review suggest that the overlapping
potential for physiological birth and, indeed, for safe moth- concepts of wisdom, skilled practice and enacted vocation
erhood. Similar observations are hinted at in other papers in may offer a basis for a theory of expert intrapartum non-
the review, although they are not expressed as fully there physician maternity care. We did not note any large varia-
(Berg & Dahlberg 2001, James et al. 2003). tions between professional groups, although this topic
remains to be fully explored in future primary research.
Our interpretation has some resonance with the attributes
Discussion
of a ‘good’ midwife described by Nicholls and Webb (2006).
Tangentially, our study also raises the question of how
Limitations
experts manage dissonance between disparate philosophies of
Although we identified many hundreds of papers that care. Practitioners working in the intrapartum setting in
addressed expertise on the basis of opinion, and many many countries are being accommodated, willingly or
quantitative papers assessing specific aspects of maternity unwillingly, into technocratic, industrialized models of care
care delivery, we found very few that fulfilled our search in the name of safety (Crabtree 2004, Mead 2004, El-Nemer
criteria of being good quality qualitative research studies. We et al. 2005). These models of care are based on assumptions
are confident that our extensive search strategy and our that birth is inherently pathological, and that rule-based
reading of all the titles generated limited the risk that we have management can minimize the risks. They are somewhat at
missed any significant English language research studies in odds with the domains of expertise identified in this study,
this area. However, we may have missed relevant studies which are more aligned with a skilled and flexible response to
published in other languages. We acknowledge that our data complex and uncertain circumstances. In the Egyptian
set was limited: three of the papers were by the same author context, we have termed this ‘skilled help from the heart’
(Kennedy 2000, Kennedy 2002, Kennedy et al. 2004) two (El-Nemer et al. 2005).
others had the same co-author (Berg & Dahlberg 2001, Our findings have significant resonance with the work of
Lundgren & Dahlberg 2002), and only two countries are Benner. Her more recent publications have built on her
represented (USA and Sweden). We have noted that disparate ‘novice to expert’ taxonomy, incorporating aspects of reflec-
criteria for ‘expertise’ were used, and that they included both tion-in-action, of caring, and of ethical and moral practice in
those with and without formal midwifery qualifications. the context of complexity (Benner et al. 1996, Benner et al.
Following the critique of Nelson and McGillion (2004) we 1999). For us, this conception of the expert may be a
recognize the risk of reification, or of circular reasoning. consequence of wisdom, skilled practice and enacted voca-
Practitioners are likely to label as ‘expert’ those practices that tion. From a feminist science perspective, such an expertise
they value, or that they feel may benefit them if they are requires the exercise of ‘hand, brain and heart’ (Rose 1983).
valued by others external to their group. We could have From a practical perspective, it requires the ability to
looked to other judges, such as labouring women themselves, minimize harm and maximize wellbeing at the complex level
or obstetricians, or hospital managers, or government health of the individual, within systems that demand rule-based

 2006 The Authors. Journal compilation  2006 Blackwell Publishing Ltd 137
S. Downe et al.

tioners to perform within the domains identified may not

What is already known about this topic deliver optimal care. If further empirical studies verify that
• Nursing and medical expertise has been widely debated the identified domains are essential for effective expert
and researched, but the nature of non-medical mater- intrapartum maternity care, education and care delivery
nity care expertise has not been systematically exam- systems will need to be designed to allow practitioners to
ined. develop and express them.
• A wide variety of practitioners provide intrapartum
maternity care.
Author contributions
• Opinions about maternity care expertise are influenced
by debates on safe motherhood on the one hand, and on SD was responsible for the study conception and design. SD,
the need to minimize unnecessary routine intrapartum LS and KT were responsible for the drafting of the manu-
interventions on the other. script. LS and KT performed the data collection. SD, LS and
KT performed the data analysis. LS obtained funding and
SD supervised the study.
What this paper adds
• Although there is a large opinion- and theory-based
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