Midwife, 3(rd) year PhD Student, City University of London, School of Health Sciences, Myddelton Street Building, City, University of London, Myddelton Street, EC1R 1UW, London, United Kingdom.
School of Health Sciences, Division of Radiography and Midwifery.
Midwifery. 2021 Jan;92:102861. doi: 10.1016/j.midw.2020.102861. Epub 2020 Oct 22.
To explore facilitators and barriers to the implementation of a physiological approach to care during labour and birth in obstetric settings. To explore how facilitators and barriers located at three levels: organisation, professional groups (midwives and obstetricians) and women, interact to influence the implementation of a physiological approach.
A systematic review of the literature, identified 32 eligible studies from four databases reporting relevant qualitative data. Findings from these studies were thematically synthesised in three phases: line by line coding of findings from primary studies, development of descriptive themes and analytical themes. This review is reported in line with PRISMA guidelines.
At an organisational level, centralisation of care in obstetric units limited time for labouring and professional care to support a physiological labour and birth. Risk management strategies ostensibly designed to promote safety sustained a risk-based approach. At a professional level, important barriers include hierarchical decision-making led by obstetricians, midwifery acquiescence, obstetric and midwifery risk preoccupation, rationalisation of the routine use of clinical intervention and an erosion of midwifery skills and knowledge. At the level of the woman, barriers include a lack of knowledge and reliance on professional decision-making. Facilitators include collaborative working by midwives and obstetricians, a valuing of midwifery autonomy and women's questioning of inappropriate intervention use.
Contrary to evidence-based guidelines that recommend a physiological approach, a risk-based approach informs practices in obstetric units. Primary research has mainly identified barriers to implementing a physiological approach at a professional level, and this has been studied largely from a midwifery perspective. To aid comprehensive investigations of facilitators and barriers and their interactive influences, this review identifies important research gaps for study across all levels: organisation, professionals (midwives and obstetricians) and women.
Risk preoccupations and rationalisation, with negative influences on knowledge and skills in the use of a physiological approach, must prompt reflection and action amongst professional groups. Power imbalances between midwives and obstetricians need to be addressed, drawing on experiences in units where collaborative working and midwifery autonomy is fostered.
探讨在产科环境中实施产时生理护理方法的促进因素和障碍因素。探讨位于组织、专业团体（助产士和产科医生）和妇女三个层面的促进因素和障碍因素如何相互作用，从而影响生理护理方法的实施。
对文献进行系统回顾，从四个数据库中确定了 32 项符合条件的研究，这些研究报告了相关的定性数据。对这些研究的结果进行了三个阶段的主题综合：对初级研究结果进行逐行编码、发展描述性主题和分析性主题。本综述按照 PRISMA 指南进行报告。
在组织层面上，产科单位的集中化护理限制了产妇和专业护理人员的时间，无法支持产时的生理护理和分娩。表面上旨在促进安全的风险管理策略维持了基于风险的方法。在专业层面上，重要的障碍包括由产科医生主导的等级决策、助产士的默认、对产科和助产风险的关注、对常规使用临床干预的合理化以及对助产技能和知识的侵蚀。在妇女层面上，障碍包括知识缺乏和依赖专业决策。促进因素包括助产士和产科医生的协作工作、对助产自主性的重视以及妇女对不适当干预使用的质疑。
与建议采用生理方法的循证指南相反，基于风险的方法为产科单位的实践提供了信息。主要的研究主要在专业层面上确定了实施生理方法的障碍，并且从助产士的角度对其进行了主要研究。为了帮助全面调查促进因素和障碍因素及其相互影响，本综述确定了在组织、专业人员（助产士和产科医生）和妇女所有层面上进行研究的重要研究差距。
对风险的关注和合理化，对使用生理方法的知识和技能产生负面影响，必须引起专业团体的反思和行动。必须解决助产士和产科医生之间的权力不平衡问题，借鉴在协作工作和助产自主性得到培养的单位的经验。
