Mapping barriers to midwives’ educational role in Cyprus guided by the Theoretical Domains Framework

Abstract

Issue The high caesarean section (C/S) rate in Cyprus (>60%) led to the formation of a National Committee to address this Public Health priority. Among WHO recommendations for C/S reduction are midwifery-led educational interventions; yet, medicalization of birth in Cyprus is curtailing the autonomous role of midwives.

Description of problem While midwives could “make every contact count” during routine appointments, antenatal education (AE) is reduced to a formal activity within the antenatal class space with documented low attendance. This formative research mapped barriers to the educational role of Cypriot midwives guided by behaviour theory. A context-specific understanding is needed to shape an appropriate intervention and promote a common understanding among stakeholders.

Results One in three midwives islandwide (N = 119, response: 34%) rated 83 determinants (from 1=more to 6=less problematic), guided by the Theoretical Domains Framework (TDF). “Beliefs about AE importance” (M = 5.57, SD = 0.96) and “Professional role” (M = 5.58, SD = 0.57) received the highest scores. Lack of organizational resources (M = 3.39, SD = 0.97), institutional and inter-professional support (M = 3.77, SD = 1.4) and acceptance (M = 4.25, SD = 0.85) were identified as problematic. While perceived capabilities and intentions were rated favourably, achieving “Goals” was difficult, mainly due to competing priorities (M = 3.86, SD = 0.84). Self-efficacy and behavioural control were lower among less experienced midwives (p < 0.01) and in the private sector (p = 0.08), which accounts for >70% of births.

Lessons Beyond the antenatal class, AE is a ‘bad fit’ with routine practice. The phenomenon pertains to organizational arrangements but also norms and perceptions of other providers and service users. While current Healthcare reforms present prospects in re-defining the role of midwives, the educational role is not adequately supported or promoted given the limited number of visits and reimbursement restrictions imposed.

Key messages • Barriers to routine antenatal education originate from an unsupportive system and socio-cultural norms which alienate midwives in an already medicalized environment.

• This theory-driven formative study described the issue in behaviour terms in the context of shaping an intervention to strengthen the health education role of midwives.