Cheer, Karen Diane (2019) Balancing it out: the process by which midwifery students provide care to women following stillbirth in Papua New Guinea. PhD thesis, James Cook University.

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Abstract

Stillbirth is a paradox of life and death. Each year, 3 million women worldwide experience stillbirth. As frontline providers of maternal health care, midwifery students and midwives are often with the woman when stillbirth occurs. The support midwifery staff provide during and after the birth contributes to how a woman recovers from her loss. Stillbirth significantly affects the wellbeing of midwifery staff, particularly midwifery students who may have little experience of stillbirth. Papua New Guinea (PNG) has one of the highest stillbirth rates in the Pacific, yet midwifery students' experiences as regards stillbirth in PNG have not been documented. This thesis helps address this gap, to inform strategies to help midwifery students cope with this often-challenging aspect of their work, thereby helping improve the provision of maternal health care in PNG.

PNG is a Pacific Island nation of 8 million people. Most of the population live a subsistence lifestyle in rural and remote village communities. With an unevenly resourced health care system, a shortage of registered midwives and inadequate infrastructure, women have limited access to maternal health care facilities and skilled care during delivery. Women typically have lower social status than men and thus have limited abilities to make individual decisions, notably in relation to their reproductive health.

This qualitative study employed constructivist grounded theory and decolonising methodologies consistent with the PNG context in which the research was conducted. Purposive sampling was used to recruit participants from a cohort of midwifery students enrolled at a PNG university. A three-phase approach was utilised over a 12-month period. Focus group discussions (n = 3) with midwifery students explored socially shared knowledge and beliefs about pregnancy, birth and stillbirth to generate initial concepts. Next, rich, semi-structured interviews (n = 11) with nine female and two male students expanded on key issues and concepts raised in the focus group discussions. A workshop with eight female students was then conducted to discuss the 'big ideas' from data analysis and conceive how ideas fit together. Transcribed audio files and workshop diagrams were analysed using constructivist grounded theory methods of initial and focused coding and categorisation to inform a developing grounded theory. The theory was presented at the study site in PNG and authenticated by people involved in the research and its outcomes.

Students' narratives show how social, cultural and religious elements of PNG life influenced the creation of meaning and determined individual and community behaviour. Students described transitioning to midwifery and their philosophical approach to care for women following stillbirth. Male students explained the challenges they faced working as student midwives when pregnancy and birth are considered women's business. In a country with diverse customs and beliefs, stillbirth is attributed to various causes. Students revealed the personal and professional consequences of caring that affected their own health and wellbeing.

'Balancing It Out' is the core category emerging from the contextual environment in which the study participants live and work. The theory describes the processes the students used in (i) 'Becoming a midwife', (ii) 'Traversing different belief systems' and (iii) 'Dealing with feelings' to achieve their aim of providing the best possible care to women following stillbirth. Providing quality midwifery care means students taking into account difficult conversations about religion, culture and social issues. Students need communication skills to have layered discussions to improve health outcomes for the women and their families.

This is the first study of midwifery students' experiences of providing care to women following stillbirth in PNG. Every midwifery student at the study site had experienced providing care to women following stillbirth prior to becoming a midwifery student. This ubiquitous experience exemplifies the need for ongoing research into interconnected social, cultural, spiritual and systemic factors that influence concepts of stillbirth and the provision of care in the PNG context.

This study is unique and there are no comparable studies from other Pacific countries, despite the high stillbirth rates across the region. However, many of the elements identified within this study correspond with findings from research investigating the provision of care to women after stillbirth by nursing students internationally. These include the psychological effects of stillbirth on students and the challenges of supporting the woman following a stillbirth delivery with holistic care that meets her social and cultural needs. The emergent themes from this study emphasise the importance of social and emotional aspects of health, and not just the biophysical. The concepts emphasise the importance of holistic care that reflects the founding principles of the World Health Organization (WHO) definition of health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (2014, p.1). The major findings of this study offer practical insights into WHO frameworks, such as the Declaration of Alma-Ata (1978) and the Ottawa Charter for Health Promotion (1986), which highlight that attaining good health requires addressing the social determinants of health. This study also offers insights into the realities of providing holistic care to women following stillbirth and the importance of advocating, enabling and mediating across health, social and economic sectors to attain the best outcomes for women following stillbirth and the midwifery staff who provide them with maternity care. Findings from this study exemplify the operational reality of these broad international documents and the importance of this unrecognised issue of care. The experiences of the midwifery students at this university demonstrate the reality for health staff, not only in PNG but also in other similar settings. The findings have practical implications for informing midwifery education and practice in PNG and provide a platform for maternal and child health research in PNG and the wider Pacific region.

As a recommendation for action, students requested specific modules in midwifery education for providing care to women experiencing stillbirth, which incorporate not only biomedical but social, cultural and spiritual aspects. Teaching of bereavement care skills would assist midwifery students in their practice and provide a balance between clinical management and social and emotional support for women. This action has begun.

Recommendations from this study have informed midwifery educators who now discuss psychosocial care for women experiencing stillbirth in course content. The new postgraduate midwifery curriculum under development will include a discrete unit on stillbirth and appropriate care for women. Self-care modules for midwifery students to build coping mechanisms to deal with the emotions they experience are also needed. Professional support and supervision for midwifery students following a critical event have the potential to reduce the effects of negative emotions on their health and wellbeing. Ongoing research is needed to assess the suitability and sustainability of these modules in the care of these women.

Item ID:	59778
Item Type:	Thesis (PhD)
Keywords:	grounded theory, qualitative research, research design, nurses, midwives, coping strategies, metasynthesis, stillbirth experiences, Papua New Guinea
Related URLs:	https://researchonline.jcu.edu.au/43034/ https://researchonline.jcu.edu.au/41212/
Copyright Information:	Copyright © 2019 Karen Diane Cheer.
Additional Information:	For this thesis, Karen Cheer received the Graduate Research School Medal of Excellence. Publications arising from this thesis are available from the Related URLs field. The publications are: Chapter 3: Cheer, Karen, MacLaren, David, and Tsey, Komla (2015) The use of grounded theory in studies of nurses and midwives' coping processes: A systematic literature search. Contemporary Nurse, 51 (2-3). pp. 200-219. Appendix A: Cheer, Karen (2016) Asia-Pacific women's experiences of stillbirth: a metasynthesis of qualitative literature. Health Care for Women International, 37 (8). pp. 889-905.
Date Deposited:	12 Aug 2019 00:10
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1110 Nursing > 111006 Midwifery @ 35% 16 STUDIES IN HUMAN SOCIETY > 1699 Other Studies in Human Society > 169905 Studies of Pacific Peoples Societies @ 35% 16 STUDIES IN HUMAN SOCIETY > 1699 Other Studies in Human Society > 169999 Studies in Human Society not elsewhere classified @ 30%
SEO Codes:	92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920507 Womens Health @ 30% 95 CULTURAL UNDERSTANDING > 9599 Other Cultural Understanding > 959999 Cultural Understanding not elsewhere classified @ 35% 97 EXPANDING KNOWLEDGE > 970116 Expanding Knowledge through Studies of Human Society @ 35%
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