Research 194 December 2017, Vol. 9, No. 4 AJHPE Childbirth is a unique and special experience for every woman. Unfortunately, however, some would argue that it is increasingly becoming a ‘medicalised’ experience, in which women lose their rights and their control over their own bodies. Studies such as that of Spurgeon et al.[1] have found that this medicalisation leaves women feeling helpless, and with no freedom of choice. The medicalisation of women’s bodies has led to widespread perceptions of childbirth as a specialist field in which only doctors have appropriate knowledge. However, it can be argued that the care that can be provided by midwives around the time of childbirth can contribute to a good start for the baby and parents during this critical period of human life. As Fraser and Cooper[2] highlight, a midwife meets a woman at the beginning of her pregnancy and provides care throughout it. If the woman has a low-risk pregnancy, the midwife works with the medical team, but (s)he is still responsible for all the midwifery care. In South Africa (SA), the midwife carries out his/her functions based on the scope of practice of a midwife,[3] keeping in mind the code of conduct and making ethical decisions regarding the care of mother and child. All midwives must realise that they are able to make independent judgments regarding the care of a patient according to their knowledge, qualification and skills. The follow-up experience is an innovation on the part of the University of the Witwatersrand (Wits) in Gauteng Province, SA. The experience provides the student midwives with the opportunity to form extended relationships with the women who they have been with during pregnancy, labour and birth, and 6 weeks after delivery. This project had been in place for 7 years prior to the time of this study. The nursing department and all institutions in which student midwives are placed for clinical education, e.g. community-service clinics, are aware of the follow-up programme, and work with students to assist and enable them to undertake the follow-up experience. All 21 student midwives who were enrolled for midwifery in the years 2009 and 2010 were given guidelines specified by the nursing department, according to which a student must: • choose one pregnant woman in her first trimester of pregnancy, and give her support throughout pregnancy, birth and postpartum until 6 weeks after delivery – i.e. (s)he will be on call throughout the woman’s journey • choose a woman perceived to be in the ‘low-risk’ category, to allow them good exposure without involving obstetricians • keep records of all their contact hours, as these would be added to their training hours as required by the SA Nursing Council regulation (R425) • keep anecdotal notes, e.g. pictures • keep journals • write narratives as (s)he continues to support the woman • exchange contact details with the woman, for communication • when visiting the woman at home, be accompanied by one of their colleagues, as some areas are dangerous to visit • by the completion of the project, have written down this experience, and must submit it for marking by the lecturer. The process of recruiting the women varied, sometimes being undertaken at the antenatal clinic of a public hospital, or at a church, or via family and friends. The follow-up experience has the potential to contribute quite significantly to the midwifery practice of students, as the time spent in these experiences is additional to their standard clinical placement. Background. In the department of nursing at the University of the Witwatersrand, South Africa, one of the requirements for students to complete their Bachelor of Nursing Science degree is to choose a pregnant woman and follow up on her care, through pregnancy, during birth and up to 6 weeks after delivery. Objective. To explore and describe student midwives’ experiences in the follow-up of a woman through pregnancy, birth, postpartum and until 6 weeks after delivery. Methods. The research design was qualitative, descriptive, exploratory and contextual. Purposive sampling was used, and 21 student midwives consented to be part of the study. Semi-structured face-to-face interviews were conducted with the student midwives after they completed the follow-up project. These interviews were tape-recorded and transcribed verbatim by an independent transcribing service. Results. The findings in relation to the research question were synthesised under three themes: building relationships with the women; challenges associated with the follow-up experience; and positive aspects of this experience. Conclusion. The follow-up experience provided midwifery students with unique and important learning opportunities that they would not have experienced in standard or hospital-based clinical placements alone. Afr J Health Professions Educ 2017;9(4):194-198. DOI:10.7196/AJHPE.2017.v9i4.730 Experiences of South African student midwives in following up on the care of a pregnant woman from pregnancy until 6 weeks after delivery L M Modiba, D Cur Department of Health Studies, College of Health Sciences, University of South Africa, Pretoria, South Africa Corresponding author: L M Modiba (modiblm@unisa.ac.za) This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Research December 2017, Vol. 9, No. 4 AJHPE 195 Problem statement I have observed that student midwives in SA believe that their prior learning in nursing education causes them to focus on task performance rather than on interaction and on offering support during midwifery training. As a new learning activity, there is no current research that indicates whether any learning actually arises from this experience, and if there is any learning, what is learnt and how this learning occurs. Little has been written about the experiences of offering continuous support during pregnancy in the SA setting. The current evaluations of the follow-up experience in the literature (Brook and Barnes[5] and Davis and McIntosh[6]) do not explore whether learning occurs as a result of this experience. From this problem, the following questions arose: • What are the personal experiences of student midwives on the follow-up of a pregnant woman from pregnancy until 6 weeks after delivery? • What are the learning experiences of student midwives when caring for a pregnant woman from pregnancy until 6 weeks after delivery? • What are the challenges associated with this follow-up experience? Purpose The purpose of this research was to determine the student midwives’ personal learning experiences in the follow-up of a pregnant woman until 6 weeks after delivery. To achieve the purpose, the following objectives were set: • to explore and describe student midwives’ personal experiences in the follow-up of a pregnant woman until 6 weeks after delivery • to identify and describe learning experiences associated with the follow- up experience • to identify and describe the challenges associated with the follow-up experience. Methodology A qualitative, exploratory, descriptive and contextual phenomenological study was undertaken to examine student midwives’ learning experiences of a follow-up of pregnant women to 6 weeks after delivery. Burns and Grove[7] have defined qualitative study design as taking a systematic, subjective approach in describing life experiences (in this study, the experiences of the student midwives) and giving them meaning. Descriptive and explorative methods are used interchangeably to gain information and to provide a picture of a situation as it naturally occurs, while contextual aspects are vital in considering the setting of the study, e.g. hospital or home.[8] This study was conducted within Witsand in a public hospital, the Charlotte Maxeke Johannesburg Academic Hospital, in Gauteng Province, SA, over a period of 2 years (2009 - 2010). Annually, the labour ward takes in about 5 000 women, who may either have uncomplicated deliveries or experience complications. In this ward, 10 student midwives from other nursing/midwifery colleges and from the university receive their clinical training. Ten qualified midwives, five doctors and six staff nurses work in this labour ward. A total of 21 student midwives were enrolled in the midwifery programme for 2 years. In the first year, they dealt with ‘normal’ midwifery, and in the second year, ‘abnormal’. Through purposive sampling, all students who were registered for midwifery volunteered to participate in this study, and signed informed consent forms in which its purpose and objectives were clearly explained. They were informed about their right to withdraw their participation at any time. Confidentiality and anonymity were maintained by not using their real names, and they were guaranteed that their names would not be given to any other person. Ethical clearance (ref. no. M10342) was received from the Wits Human Research Ethics Committee. The students were aged between 21 and 26 years old, and only four had had personal experience of childbearing. At the antenatal clinic of the public hospital, the pregnant women were informed by the qualified midwives about the need for student midwives to gain follow-up experience of pregnant women; therefore, when the student midwives came to recruit them, they were already aware of the programme. The student midwives chose women they were comfortable with, according to either language or culture. On orientation in class, students were also informed that they could choose to follow up a family member, friend or fellow congregant, as long as they received the individual’s permission. Data collection Semi-structured face-to-face interviews were conducted with the student midwives after completing this project. In order to manage the issue of potential intimidation, as I was their lecturer, I asked a midwifery colleague who also has experience with qualitative interviews to conduct the interviews. I then provided the interviewer with an overview of the research and the interview questions, and introduced her to the students after informing them that they would be interviewed. These interviews were tape-recorded and transcribed verbatim by an independent transcribing service. Student midwives were asked to keep journals and to write narratives throughout the experience, which also formed part of the data collected. The purpose was to assist the student midwives to reflect on and evaluate their experiences in offering continuous support. The students were asked to describe their experiences of the follow- up of the pregnant women. Data analysis A qualitative content analysis was used to allow me to interpret the underlying meanings of the texts, as suggested in the literature by Graneheim and Lundman.[9] As I was also these students’ lecturer, and involved in marking their portfolios, the experiences and narratives documented were read, and meaningful units were identified. These units consisted of text from a few words up to several sentences, the meanings of which were interpreted. During the interpretation, subthemes were identified, and a main theme emerged at the end of this process. The findings in relation to the research questions can be synthesised under three themes: personal experiences associated with follow-up; learning experiences associated with follow-up; and challenges associated with the follow-up experience. The results of the analysis are presented below under these headings. Personal experiences associated with follow-up Under this theme, three subthemes emerged: ‘getting to know what makes the woman tick’; ‘the woman’s care is in your hands’; and feeling under a lot of pressure. ‘Getting to know what makes the woman tick’ Students perceived the follow-up experience to be focused on the woman, rather than anything else. Getting to know the woman was more than a simple social activity. It involved a deeper relationship that led to the Research 196 December 2017, Vol. 9, No. 4 AJHPE midwifery student learning about the woman’s wider environment and personal circumstances. One participant explained: ‘You really get to know, especially with home visits, what her home environment is like and how that’s impacting on the person that she is and the choices that she is going to make.’ This theme shows the student becoming deeply involved in the follow-up experience and learning from it. This relationship is built on important facets such as the relationship with her family or partner, demonstrating that this is more than a simple social interaction. ‘The woman’s care is in your hands’ The theme involves the student learning from engaging with the woman and feeling that this puts the woman’s care in their hands. This was described by one student as follows: ‘You actually get to speak to a real person rather than just reading books or just practising on dolls. It is a lot different in the real world than sitting and reading a textbook. You learn that not every labour is like a textbook labour.’ Feeling under a lot of pressure Students felt under a lot of pressure because of the overload of work from other subjects, e.g. community-health nursing sciences, while they could also be interrupted by their follow-up woman at any time. This was articulated as follows: ‘I will be sleeping and when a phone rang would say dear God, I hope this is not my follow-up woman. I had a young child and still married, and if called at that time it is really a difficult time. It was gruelling!’ In summarising this theme, most of the participants felt that this experience exposed them to getting to know the woman better, so that the care they were providing was centred on trust. The experience clearly identified interaction where a significant relationship was built. Some participants articulated the difficulties they were exposed to when they were having family problems. Learning associated with experiences Under this theme, three subthemes also emerged: ‘being there in the moment’; relationship-building with the woman; and the uniqueness of each woman’s journey. ‘Being there in the moment’ This illustrates how learning took place, and it was described by one participant as: ‘What I have learned through this experience is more than what I have learned in class.’ Another participant said ‘It has been a deep learning experience because one gets to see the transformation that pregnancy, birth and motherhood brings and what impacts on this. Not just fragments of this from the textbooks, it has taught me about taking personal responsibility as a midwife.’ Relationship-building with the woman Student midwives in this study stressed that the relationships they formed with these women during this time were important for a number of reasons – they knew about the woman, her wishes, her past experiences and her personal circumstances, and they came to understand what impact these had on her experience of pregnancy, labour and early parenting. These relationships meant that the students were able to provide care that was personal and tailored for that particular woman. They described how they came to realise that being able to get to know the woman was a valuable opportunity: one student midwife said ‘It has given me a “bigger picture” approach – holistic care as well as teaching me that my beliefs really have little relevance and it comes about to the woman’s own choices that matters.’ The experience provided student midwives with an opportunity to form extended relationships with the women. Being present Students reported that the women did not want to be left alone during labour. The presence of the student helped the women to relax and feel more secure. The student’s presence was expressed by touch or talking, as one participant described: ‘The woman wanted me to hold my hand on her belly at every contraction. At first I found it odd. I wondered how it could help her, but then I saw that it really did. To her it was probably important to feel that I was actually there. It seemed it made her to relax.’ Another said: ‘I learned that one sometimes does not have to do so much for the woman, it can be enough just to be there for her and to listen.’ According to Hunter,[10] ‘presence’ involves a willing interaction between the midwife and the woman, which requires trust on the part of the woman, and the giving of self (engagement, attentiveness, time and awareness of the encounter) by the midwife. This has also been recognised by Kennedy et al.,[11] who consider the art of midwifery as being present without interfering; as long as the process is working as it should, midwifery is the art of ‘doing “nothing” well’. Feeling of trust Student midwives also felt that the women trusted them because they knew them, and that this trust was significant for the women. They recognised the value of having an existing relationship prior to labour and birth, as identified by participants: ‘There’s a better trust there, and it feels a bit more like almost a friendship or a partnership with the woman.’ ‘It is so much easier and rewarding to care for women in a continuity of care. The birth experience in particular becomes so less scary for women when they feel well supported by a known and trusted person.’ The uniqueness of each woman’s journey Some participants described how they learnt about how women experience their journey. One participant said: ‘I have learned that pregnancy and birth is a different experience for all women and one should not make any assumptions about how women experience it.’ Another one explained: ‘They have all been different so far and each and every one had something special. The issues that came up woke my curiosity and got me reading more.’ In summarising this theme, student midwives recognised that the development of a relationship and a commitment to the woman allowed them to provide her with the type of care that they knew was appropriate for her, particularly during her labour and birth. Midwifery literature (Kirkham[4] and Hunter[12]) has previously shown that midwives experience work differently when they are able to build relationships with women. According to Fraser et al.,[13] it is through the development of relationships between caregivers and childbearing women and their families that we make the change from ‘faceless institution’ to ‘humanistic supportive care’. Challenges associated with the follow-up experience While student midwives spoke of their experiences of being able to develop relationships with women, they also articulated aspects of the follow- Research December 2017, Vol. 9, No. 4 AJHPE 197 up experience that were difficult: recruiting; poor support; conflicting priorities; finances; and intimidation. Recruiting The student midwives described the recruitment of a woman for follow-up as a difficult and challenging experience, and it was explained as awkward and sometimes time-consuming, as indicated in the following statements: ‘I was frustrated because she couldn’t understand me well. I spoke too quickly for her but I corrected myself and the communication between us grew. My first feeling was that she would be just another attempt, soon she would not come for the visits any longer and I would be sitting in looking for a new woman.’ ‘At the start of the project I wanted to quit because of fear of rejection, but because time was running out I had to do it. It is also a very confronting experience to have to ask a woman if you can be a part of this very intimate time of her life.’ In summarising this theme, it was clear that there were difficulties associated with recruiting women, e.g. it was awkward, and it sometimes took a long time as the participants were also supposed to study and manage work and family life. Poor support Student midwives received some support from the university, midwives, doctors and their colleagues, but it was not always sufficient, and this was reaffirmed by a student midwife who described how midwives did not ring her for the labour and birth: ‘My follow-up woman asked the midwife to call me as soon as she was admitted but the midwife did not do it. So, I missed out on being at the birth.’ Another student explained: ‘After my follow-up woman lost her child, I walked to an empty room and I sat alone and cried. I was interrupted when a nursing sister walked in the room and began shouting at me, saying that is her room, at least she stopped when she saw my puffy eyes, and she asked me and I told her that I was crying because my baby died to which she replied ‘Oh!’ And she continued to read her newspaper. I asked myself where her compassion was!’ This showed poor professional support from qualified midwives. One participant explained that sometimes one develops an emotional attachment and this becomes difficult: ‘You can never predict how a birth will end up, I also found the woman to be more trusting and confident in labour. I actually preferred not to know them well as it interfered with my clinical judgement. I was too emotionally involved.’ Conflicting priorities One concern was about the difficulties associated with trying to balance university requirements with the follow-up experience. This was revealed in the following comment: ‘I had to miss the appointment with my follow-up woman as I was on the train for community clinical placement in another province.’ This illustrates that although this project was supported by the university, there were clashes as students were also registered for other courses than midwifery, e.g. psychiatry and community-health nursing. Finances Although the university recognises the follow-up project, difficulties were encountered when student midwives needed to spend money on things such as purchasing cellphone credit in order to call their follow-up woman, and paying for transport when visiting the woman at home. This was illustrated by the following statement: ‘I had to purchase phone credit in order to communicate with the woman. And when I went to visit her at home I bought fruits for her other kids and at the same time had to pay transport money.’ In summary, the student midwives explained that although students are required to commit time, other resources are also needed, such as travel expenses to visit the women at home. Intimidation Students had to follow up some of the women at home in order to get to know them as members of their families, and to understand the environment in which they were living. The general experience was found to be intimidating, especially if the woman was not at home. This was described by one participant: ‘When I arrived there I found the partner who welcomed me and as I was asking as to where Ms X was, he mentioned that she is gone to the homestead, but surprisingly he start to flirt with me and I had to go out of that place running.’ The student midwives, in summary, mentioned that it was not always safe to travel alone, as sometimes they would be faced with awkward situations at the homes of the women, or risked being robbed. Discussion The research showed that the implementation of a follow-up woman programme has many benefits to both student midwives and women during their pregnancy, delivery and postnatal period. If care is appropriately organised, and midwives gain interpersonal and clinical skills and knowledge, it is more likely to be successful. The way care is organised, including the pattern and culture of practice, is probably one of the most important factors in creating effective, sensitive and individual care.[13] It is important that midwives ensure continuity of care to mothers and babies throughout pregnancy, the birth experience and the puerperium. ‘Continuity of care’ refers to the follow-up of a woman to ensure that her needs – both physical and psychological – are met in each consultation, and that the same midwife continues to care for her throughout the period from early pregnancy to after birth. In this way, in any given encounter with the maternity services, a woman can feel confident that her caregiver will know what has gone before, so that she will not have to repeat her story yet again. Equally, decisions about her care will have been made as a result of policies that are shared by all her caregivers and to which all are willing to adhere, so that she will not be given conflicting advice. This is further articulated by Homer et al.,[14] who argue that continuity of the carer refers to care by a midwife whom the woman has met previously and feels that she knows. A lot is gained through continuity of care, such as the trust and co-operation of the patient in solving issues at any time in pregnancy and labour. This is supported by Pairman,[14] who refers to the woman-student relationship, and the learning that the student gains from this experience, as powerful. It also increases the quality of care of the woman in the sense that the midwife has the opportunity to understand her background and culture, to get to know her more deeply and to allow the establishment of a relationship between them. When in labour, the woman will have support from someone whom she already knows and has a trusting relationship with. This is confirmed by Fraser et al.:[13] women identified good communication skills to be of primary importance, although some women also wanted more than this and expected midwives to have a special relationship with them. The pregnant woman may also come to Research 198 December 2017, Vol. 9, No. 4 AJHPE feel comfortable enough to question the midwife and to participate in any decision-making. Each labour is a unique experience, and greater experience with diverse labours means midwives will experience fewer caesarean-section cases and more successful second stages of labour, in terms of a shorter second stage and intact perineum.[16] Midwifery offers the possibility of making the childbirth experience of a woman special and unique, and the experience can also end up being just as unique to the midwife, because with each woman, the midwife is able to create a different and personal bond. As midwives, we can empower women and make a difference for them, at the same time creating a learning opportunity for ourselves.[17] Conclusions The follow-up experience provided a significant learning environment for midwifery students. Students identified the learning they received from the experience as uniquely individual. They articulated that they learned through interaction with each woman, and their ability to be hands-on with her. The follow-up experience provided midwifery students with unique and important learning opportunities that they would not experience in standard or hospital-based clinical placements alone. These learning experiences occur primarily because students are paired with individual women. It is this relationship that provides serendipitous learning, in which learning is informal, the knowledge gained is high and motivation remains with the learner. Students are likely to learn more from these experiences if they are embedded within courses, where support is provided for reflection, and where they are not forced to take a superficial approach to care as a result of an excessive workload. Acknowledgements. I would like to thank the students who agreed to participate in this study. Author contributions. Sole author. Funding. None Conflicts of interest. None 1. Spurgeon P, Hicks C, Barwell F. Antenatal, delivery and postnatal comparisons of maternal satisfaction with two pilot Changing Childbirth schemes compared with a traditional model of care. Midwifery 2001;17(2):123-132. https://doi.org/10.1054/midw.2001.0255 2. Fraser MD, Cooper IS. Myles Textbook for Midwives, 14th ed. New York: Churchill Livingstone, 2003. 3. South African Nursing Council. Scope of Practice of a Registered Midwife. No: R2488. Pretoria: SANC, 1990. 4. Kirkham M. The Midwife-Mother Relationship. Basingstoke: Macmillan, 2000. 5. Brooks C, Barnes M. Experience-based educational strategies to promote woman-cantered midwifery practice. Aust J Midwifery 2001;14(1):22-26. https://doi.org/10.1016/s1445-4386(01)80031-8 6. Davis D, McIntosh C. Partnership in education: The involvement of service users in one midwifery program in New Zealand. Nurs Educ Pract 2005;5,274-280. https://doi.org/10.1016/j.nepr.2005.02.002 7. Burns N, Grove SK. The Practice of Nursing Research: Conduct, Critique and Utilization, 5th ed. St Louis: Elsevier/Saunders, 2007. 8. Lobiondo-Wood G. Nursing Research Methods: Clinical Appraisal for Evidenced-Based Practice, 6th ed. St Louis: Mosby, 2006. 9. Graneheim UP, Lundman E. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 2004;24(2):105-112. https://doi.org/10.1016/j.nedt.2003.10.001 10. Hunter B. The importance of reciprocity in relationships between community-based midwives and mothers. Midwifery 2006;22(4):308-328. https://doi.org/10.1016/j.midw.2005.11.002 11. Kennedy H, Shannon U, Chuahorm U, Kravetz M. The landscape of caring for women: A narrative study of midwifery practice. J Midwifery Womens Health 2004;49(1):14-23. https://doi.org/10.1111/j.1542-2011.2004. tb04403.x 12. Hunter LP. Being with woman: A guiding concept for the care of labouring women. J Obstetric Gynecol Neonatal Nurs 2002;31(6):650-657. https://doi.org/10.1177/088421702129005281 13. Fraser MD, Cooper AM, Nolte AGW. Myles Textbook for Midwives, African Edition. Edinburgh: Churchill Livingstone, 2006. 14. Homer CS, Davis GK, Cooke M, Barclay L. Women’s experiences of continuity of midwifery care in a randomised controlled trial in Australia. Midwifery 2002;18(2):102-112. https://doi.org/10.1054/midw.2002.0298 15. Pairman S, Massey S. Where do all the midwives go? A report on the practice choices made by Bachelor of Midwifery graduates. N Z Coll Midwives J 2001;25:16-22. 16. Halldorsdottir S, Karlsdottir SI. Journeying through labour and delivery: Perceptions of women who have given birth. Midwifery 1996;12(2):48-61. https://doi.org/10.1016/s0266-6138(96)90002-9 17. Lavender T, Walkinshaw SA, Walton I. A prospective study of women’s views of factors contributing to a positive birth experience. Midwifery 1999;15(1):40-46. https://doi.org/10.1016/s0266-6138(99)90036-0 Accepted 27 March 2017. https://doi.org/10.1054/midw.2001.0255 https://doi.org/10.1016/s1445-4386(01)80031-8 https://doi.org/10.1016/j.nepr.2005.02.002 https://doi.org/10.1016/j.nedt.2003.10.001 https://doi.org/10.1016/j.midw.2005.11.002 https://doi.org/10.1111/j.1542-2011.2004.tb04403.x https://doi.org/10.1111/j.1542-2011.2004.tb04403.x https://doi.org/10.1177/088421702129005281 https://doi.org/10.1054/midw.2002.0298 https://doi.org/10.1016/s0266-6138(96)90002-9 https://doi.org/10.1016/s0266-6138(99)90036-0