Maternity Early Warning Tools and Midwifery Practice - The Coalescence of Perceptions, Practice and Power: A Grounded Theory

Introduction: Quality midwifery practice is vital in achieving favourable perinatal outcomes. Contemporary healthcare is increasingly framed by risk management, which impacts midwifery practice. One risk management strategy is using Maternity Early Warning Tools (MEWTs). This grounded theory study explored the complex interplay between enacting midwifery practice and risk management related to MEWTs.

Aim: To understand how Australian midwives enact practice when using an Early Warning Tool during intrapartum care. The intrapartum period in this study is defined as the onset of active labour, encompassing the infant’s birth, with completion being the placental birth (Thorpe & Anderson, 2018).

Background: In recent decades, global attention has been directed towards implementing early warning tools and associated technology in healthcare to mitigate risks, enhance outcomes, and lower expenses (Li et al., 2019; MacIntyre et al., 2023). Maternity services also implemented early warning systems, adapting adult early warning systems for use (Cantwell et al., 2011; Cole, 2014). The tools implemented in maternity services are known by various terms such as Maternal Early Warning System (MEWS), Maternal Early Warning Tool (MEWT) or Modified Early Obstetric Warning System (MEOWS) and for this study, the term MEWT will be applied (Al-Foudri et al., 2010; Knight, 2019; Kenyon et al., 2015). Initially, early warning tools were developed for general adult populations without specific consideration of the context of labour and childbirth (Royal College of Physicians, 2012). However, MEWTs have since been adapted from the adult version, aiming to accommodate the physiological changes of pregnancy and the expected changes in maternal vital signs that recognise the unique signs and symptoms of deterioration and increasing risk for an obstetric population (Drake et al., 2021; Lapinsky et al., 2011; Lappen et al., 2010; Umar et al., 2019).

Methodology/methods: This study used a Straussian grounded theory approach supplemented with Clarke’s situational analysis. Data was collected through purposive and theoretical sampling, which resulted in 18 registered midwives participating in semi-structured interviews. Analysis was conducted according to the tenets of grounded theory.

Findings: The final theory from this study, the Coalescence of Perceptions, Practice and Power, explains the impact of early warning tools on midwives’ professional behaviours and their approach to care across various levels of experience and seniority. The coalescence of perceptions, practice and power refers to the process by which midwives reconcile and balance their own power and perceptions to that of the system within which they operate. The three categories that comprise the final theory are: ‘perceptions and behaviours’, ‘shifting practice’ and ‘power in practice.’

Conclusions: Institutional systems, being risk-averse, have lent towards a risk-averse techno-rational approach, thus shifting midwifery practice. Institutional authority and requirements, external to the clinician-person relationship, influence the ability to enact practice, specifically, the degree to which mandated practice controls how care is delivered. Implementing a MEWTs can contribute to reduced agency and the standardisation of care yet may provide a safety net.

Contribution to the field of knowledge: The research contributes to a deeper understanding of how midwives navigate contemporary healthcare challenges, particularly in balancing standardised care with individual women’s needs.