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  • 1. Ahrne, Malin
    et al.
    Schytt, Erica
    Andersson, Ewa
    Small, Rhonda
    Adan, Aisha
    Essén, Birgitta
    Byrskog, Ulrika
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives2019In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 74, p. 107-115Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore Somali-born parents' experiences of antenatal care in Sweden, antenatal care midwives´ experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents.

    DESIGN: Eight focus group discussions with 2-8 participants in each were conducted, three with Somali-born mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling´s tool "Thematic networks".

    SETTING: Two towns in mid-Sweden and a suburb of the capital city of Sweden.

    PARTICIPANTS: Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling.

    FINDINGS: Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth.

    KEY CONCLUSIONS: ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed.

  • 2. Avelin, Pernilla
    et al.
    Rådestad, Ingela
    Säflund, Karin
    Wredling, Regina
    Erlandsson, Kerstin
    Mälardalen University.
    Parental grief and relationships after the loss of a stillborn baby2012In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 6, p. 668-673Article in journal (Refereed)
  • 3.
    Avelin, Pernilla
    et al.
    Mälardalens högskola, Akademin för hälsa, vård och välfärd.
    Rådestad, Ingela
    Sophiahemmet Univ Coll.
    Säflund, Karin
    Karolinska Inst.
    Wredling, Regina
    Karolinska Inst.
    Erlandsson, Kerstin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Mälardalens högskola, Akademin för hälsa, vård och välfärd.
    Parental grief and relationships after the loss of a stillborn baby2013In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 6, p. 668-73Article in journal (Refereed)
    Abstract [en]

    Objectives: to describe the grief of mothers and fathers and its influence on their relationships after the loss of a stillborn baby.

    Design: a postal questionnaire at three months, one year and two years after stillbirth.

    Setting: a study of mothers and fathers of babies stillborn during a one-year period in the Stockholm region of Sweden.

    Participants: 55 parents, 33 mothers and 22 fathers.

    Findings: mothers and fathers stated that they became closer after the loss, and that the feeling deepened over the course of the following year. The parents said that they began grieving immediately as a gradual process, both as individuals, and together as a couple. During this grieving process their expectations, expressions and personal and joint needs might have threatened their relationship as a couple, in that they individually felt alone at this time of withdrawal. While some mothers and fathers had similar grieving styles, the intensity and expression of grief varied, and the effects were profound and unique for each individual.

    Key conclusions: experiences following a loss are complex, with each partner attempting to come to terms with the loss and the resultant effect on the relationship with their partner.

    Implications for practice: anticipating and being able to acknowledge the different aspects of grief will enable professionals to implement more effective intervention in helping couples grieve both individually and together.

  • 4. Bogren, Malin
    et al.
    Sathyanarayanan, Doraiswamy
    Erlandsson, Kerstin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Akhter, Halima
    Akter, Dalia
    Begum, Momtaz
    Chowdhury, Merry
    Das, Lucky
    Akter, Rehana
    Khatun, Yamin Ara
    Development of a context specific accreditation assessment tool for affirming quality midwifery education in Bangladesh2018In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 61, p. 74-80Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: using the International Confederation of Midwives (ICM) Global Standards for Midwifery Education as a conceptual framework, the aim of this study was to explore and describe important 'must haves' for inclusion in a context-specific accreditation assessment tool in Bangladesh.

    DESIGN: A questionnaire study was conducted using a Likert rating scale and 111 closed-response single items on adherence to accreditation-related statements, ending with an open-ended question. The ICM Global Standards guided data collection, deductive content analysis and description of the quantitative results.

    SETTING: twenty-five public institutes/colleges (out of 38 in Bangladesh), covering seven out of eight geographical divisions in the country.

    PARTICIPANTS: one hundred and twenty-three nursing educators teaching the 3-year diploma midwifery education programme.

    FINDINGS: this study provides insight into the development of a context-specific accreditation assessment tool for Bangladesh. Important components to be included in this accreditation tool are presented under the following categories and domains: 'organization and administration', 'midwifery faculty', 'student body', 'curriculum content', 'resources, facilities and services' and 'assessment strategies'. The identified components were a prerequisite to ensure that midwifery students achieve the intended learning outcomes of the midwifery curriculum, and hence contribute to a strong midwifery workforce. The components further ensure well-prepared teachers and a standardized curriculum supported at policy level to enable effective deployment of professional midwives in the existing health system.

    KEY CONCLUSIONS: as part of developing an accreditation assessment tool, it is imperative to build ownership and capacity when translating the ICM Global Standards for Midwifery Education into the national context.

    IMPLICATIONS FOR PRACTICE: this initiative can be used as lessons learned from Bangladesh to develop a context-specific accreditation assessment tool in line with national priorities, supporting the development of national policies.

  • 5.
    Byrskog, Ulrika
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Essén, Birgitta
    Olsson, Pia
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    ‘Moving on’: Violence, wellbeing and questions about violence in antenatal care encounters. A qualitative study with Somali-born refugees in Sweden2016In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 40, p. 10-17Article in journal (Refereed)
    Abstract [en]

    Background

    Somali-born women constitute one of the largest groups of childbearing refugee women in Sweden after more than two decades of political violence in Somalia. In Sweden, these women encounter antenatal care that includes routine questions about violence being asked. The aim of the study was to explore how Somali-born women understand and relate to violence and wellbeing during their migration transition and their views on being approached with questions about violence in Swedish antenatal care.

    Method

    Qualitative interviews (22) with Somali-born women (17) living in Sweden were conducted and analysed using thematic analysis.

    Findings

    A balancing actbetween keeping private life private and the new welfare system was identified, where the midwife's questions about violence were met with hesitance. The midwife was, however, considered a resource for access to support services in the new society. A focus on pragmatic strategies to move on in life, rather than dwelling on potential experiences of violence and related traumas, was prominent. Social networks, spiritual faith and motherhood were crucial for regaining coherence in the aftermath of war. Dialogue and mutual adjustments were identified as strategies used to overcome power tensions in intimate relationships undergoing transition.

    Conclusions

    If confidentiality and links between violence and health are explained and clarified during the care encounter, screening for violence can be more beneficial in relation to Somali-born women. The focus on “moving on” and rationality indicates strength and access to alternative resources, but needs to be balanced against risks for hidden needs in care encounters. A care environment with continuity of care and trustful relationships enhances possibilities for the midwife to balance these dual perspectives and identify potential needs. Collaborations between Somali communities, maternity care and social service providers can contribute with support to families in transition and bridge gaps to formal social and care services.

  • 6. Cleeve, Amanda
    et al.
    Nalwadda, Gorette
    Zadik, Tove
    Sterner, Kathy
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Morality versus duty - A qualitative study exploring midwives' perspectives on post-abortion care in Uganda2019In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 77, p. 71-77Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We aimed to explore midwives' perspectives on post-abortion care (PAC) in Uganda. Specifically, we sought to improve understanding of the quality of care.

    DESIGN: This was a qualitative study using individual in-depth interviews and an inductive thematic analysis.

    SETTING AND PARTICIPANTS: Interviews were conducted with 22 midwives (the 'informants') providing PAC in a public hospital in Kampala, Uganda. The narratives were based on experiences in current and previous workplaces, in rural and urban settings.

    FINDINGS: The findings comprise one main theme - morality versus duty to provide quality post-abortion care - and three sub-themes. Our findings confirm that the midwives were committed to saving women's lives but had conflicting personal morality in relation to abortion and sense of professional duty, which seemed to influence their quality of care. Midwives were proud to provide PAC, which was described as a natural part of midwifery. However, structural challenges, such as lack of supplies and equipment and high patient loads, hampered provision of good quality care and left informants feeling frustrated. Although abortion was often implied to be immoral, the experience of PAC provision appeared to shape views on legality, leading to an ambiguous, yet more liberal, stance. Abortion stigma was reported to exist within communities and the health workforce, extending to both providers and care-seeking women. Informants had witnessed mistreatment of women seeking care due to abortion complications, through deliberate care delays and denial of pain medication.

    KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives in PAC were dedicated to saving women's lives; however, conflicting morality and duty and poor working conditions impeded quality of care. Enabling midwives to provide good quality care includes increasing the patient-midwife ratio and ensuring essential resources are available. Additionally, efforts that de-stigmatise abortion and promote accountability are needed. Implementation of policies on respectful post-abortion care could aid in ensuring all women are treated with respect.

  • 7.
    Erlandsson, Kerstin
    et al.
    Mälardalen University.
    Fagerberg, Ingegerd
    Mothers' lived experiences of co-care and part-care after bith, and their strong desire to be close to their baby2005In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 21, no 2, p. 131-138Article in journal (Refereed)
  • 8.
    Erlandsson, Kerstin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Mälardalens högskola, Akademin för hälsa, vård och välfärd.
    Warland, J.
    School of Nursing and Midwifery, University of South Australia.
    Cacciatore, J.
    School of Social Work, Arizona State University.
    Rådestad, I.
    Sophiahemmet University College.
    Seeing and holding a stillborn baby: mothers' feelings in relation to how their babies were presented to them after birth - findings from an online questionnaire2013In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 3, p. 246-250Article in journal (Refereed)
    Abstract [en]

    Objective: to determine if the way caregivers offer opportunities to see and hold a stillborn baby impacts a mother's feelings about the experience of seeing and holding her newborn.

    Design and setting: a web questionnaire hosted by the Swedish National Infant Foundation from March 2008 to April 2010.

    Participants: 840 eligible participants who had experienced a stillbirth after the 22nd gestational week from 1955 to 2010 and completed an online questionnaire about their experiences.

    Methods: descriptive and inferential statistics.

    Findings: when mothers were presented the baby as a normal part of birth without being asked if they wanted to see, they more often reported that the experience was comfortable compared to mothers who were asked if they wanted to see the baby 86% vs. 76% (p=<0.01). The incitation of fear in mothers was 70% vs. 80% (p=0.02) in favour of mothers who were not asked. Furthermore the mothers who were not asked more often stated that it felt natural and good when compared to those who said staff asked if the mother wanted to see, 73% vs. 61% (p=0.07) and (78%) vs. (69%) p=0.19, respectively. A trend was seen toward more mothers feeling natural, good, comfortable, and less frightened if the provider engaged in 'assumptive bonding', that is the baby is simply and naturally presented to the mother without asking her to choose.

    Key conclusions: mothers of stillborn babies felt more natural, good, comfortable and less frightened if the staff supported assumptive bonding by simply offering the baby to the mother. Implications for practice: care providers should approach caring for grieving mothers with tenderness and humility, assuming that they will wish to see and hold their stillborn baby. 

  • 9.
    Klingberg-Allvin, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hatakka, Mathias
    Dalarna University, School of Technology and Business Studies, Information Systems.
    Erlandsson, Kerstin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Osman, Fatumo
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Byrskog, Ulrika
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Egal, Jama
    "Change-makers in midwifery care": Exploring the differences between expectations and outcomes - a qualitative study of a midwifery net-based education programme in the Somali region2019In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 69, p. 135-142Article in journal (Refereed)
    Abstract [en]

    The aim of this study is to explore midwifery educators’ expected outcomes in the net-based master's programme, the programmes’ realised outcomes and the reported difference regarding the increased choices for the graduates and the effect on their agency.

    Design

    In this case study, we focused on a net-based master's programme in sexual and reproductive health in Somalia. Somalia suffers from a shortage of skilled birth attendants and there is a need for building up the capacity of midwifery educators.

    Setting and participants

    Data was collected in focus group discussions at the start of the programme and eight months after the students graduated. The data were analysed through the lens of the choice framework, which is based on the capability approach.

    Findings

    Findings show that many of the graduates’ expectations were met, while some were more difficult to fulfil. While the midwives’ choices and resource portfolios had improved because of their role as educators, the social structure prevented them from acting on their agency, specifically in regards to making changes at the social level. Several of the positive developments can be attributed to the pedagogy and structure of the programme.

    Conclusion

    The flexibility of net-based education gave the midwifery educators a new educational opportunity that they previously did not have. Students gained increased power and influence on some levels. However, they still lack power in government organisations where, in addition to their role as educators, they could use their skills and knowledge to change policies at the social level.

  • 10.
    Lindgren, Helena
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Christensson, Kyllike
    Hildingsson, Ingegerd
    Rådestad, Ingela
    Walley-Byström, K
    Perceptions of risk and risk management among 735 women who opted for a home birth2010In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 26, no 2, p. 163-172Article in journal (Refereed)
    Abstract [en]

    Home birth is not included in the Swedish health care system and the rate for planned home births is less than one in a thousand. The aim was to describe women’s perceptions of risk related to childbirth and the strategies for managing these perceived risks. Design and setting A nationwide study including all women who had given birth at home in Sweden was conducted between 1 January 1992 and 31 July 2005. Participants A total of 735 women had given birth to 1038 children. Of the 1038 questionnaires sent to the women, 1025 (99%) were returned. Measurements Two open questions regarding risk related to childbirth and two questions answered by using a scale were investigated by content analysis. Findings Regarding perceived risks in a hospital birth, three categories, all related to loss of autonomy, were identified: 1) being in the hands of strangers; 2) being in the hands of routines and unnecessary interventions and 3) being in the hands of structural conditions. Perceived risks related to a home birth were associated with a sense of being beyond help; 1) worst case scenario and 2) distance to the hospital. The perceived risks were managed by using extrovert activities and introvert behaviour and by avoiding discussions concerning risks with health care professionals. Conclusion Women who plan for a home birth in Sweden do consider risks related to childbirth but they avoid talking about the risks with health care professionals. Implications for practice To understand why women choose to give birth at home, health care professionals must learn about the perceived beneficial effect of doing so.

  • 11.
    Lindgren, Helena
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Hildingsson, Ingegerd
    Rådestad, Ingela
    A Swedish interview study: parents' assessment of risks in home births.2006In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 22, no 1, p. 15-22Article in journal (Refereed)
    Abstract [en]

    Objective: to describe home-birth risk assessment by parents. Design: interviews using a semi-structured interview guide. Data were analysed using a phenomenological approach. Setting: independent midwifery practices in Sweden. Participants: five couples who had had planned home births. Findings: the parents had a fundamental trust that the birth would take place without complications, and they experienced meaningfulness in the event itself. Risks were considered to be part of a complex phenomenon that was not limited to births at home. This attitude seems to be part of a lifestyle that has a bearing on how risks experienced during the birth were handled. Five categories were identified as counterbalancing the risk of possible complications: (1) trust in the woman’s ability to give birth; (2) trust in intuition; (3) confidence in the midwife; (4) confidence in the relationship; and (5) physical and intellectual preparation. Key conclusions: although the parents were conscious of the risk of complications during childbirth, a fundamental trust in the woman’s independent ability to give birth was central to the decision to choose a home birth. Importance was attached to the expected positive effects of having the birth at home. Implications for practice: knowledge of parents’ assessment can promote an increased understanding of how parents-to-be experience the risks associated with home birth.

  • 12. Påfs, Jessica
    et al.
    Musafili, Aimable
    Finnema, Pauline Binder
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Rulisa, Stephen
    Essén, Birgitta
    'They would never receive you without a husband': Paradoxical barriers to antenatal care scale-up in Rwanda2015In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 31, no 12, p. 1149-1156Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss').

    DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda.

    FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy.

    CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

  • 13.
    Rådestad, Ingela
    et al.
    Sophiahemmet Högskola.
    Malm, Mari-Cristin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Women's and Children's Health, Uppsala University, Sweden.
    Lindgren, Helena
    Sahlgrenska Akademin, Göteborgs Universitet.
    Pettersson, Karin
    Karolinska institutet.
    Franklin Larsson, Lise-Lotte
    Ersta University .
    Being alone in silence: mothers' experiences upon confirmation of their baby´s death in utero2013In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 30, no 1, p. E91-E95Article in journal (Refereed)
    Abstract [en]

    Objective: To explore mothers' experiences of the confirmation of ultrasound examination results and how they were told that their baby had died in-utero.

    Design: In-depth interviews.SettingSweden.

    Participants: 26 mothers of stillborn babies.

    Measurement: Narratives were analysed using a qualitative content analysis with an inductive approach.

    Findings: The mothers experienced that silence prevailed during the entire process of confirming the ultrasound results. Typically all present in the ultrasound room were concentrating and focusing on what they observed on the screen, no one spoke to the mother. The mothers had an instinctive feeling that their baby might be dead based on what they observed on the ultrasound screen and on their interpretation of the body language of the clinicians and midwives. Some mothers reported a time delay in receiving information about their baby's death. Experiencing uncertainty about the information received was also noticed.

    Conclusion: Mothers emphasised an awareness of silence and feelings of being completely alone while being told of the baby's death.Implication for practicethe prevalence of silence during an ultrasound examination may in certain cases cause further psychological trauma for the mother of a stillborn baby. One way to move forward given these results may be to provide obstetric personnel sufficient training on how difficult information might be more effectively and sensitively provided in the face of an adverse pregnancy outcome.

  • 14.
    Schytt, Erica
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Department of Women's and Children's Health, Division of Reproductive and Perinatal Health, Karolinska Institutet.
    Waldenström, Ulla
    How well does midwifery education prepare for clinical practice? Exploring the views of Swedish students, midwives and obstetricians2013In: Midwifery, ISSN 0266-6138, E-ISSN 1532-3099, Vol. 29, no 2, p. 102-109Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: midwifery education in many countries has been adapted to the academic system by a stronger focus on research methodology and scientific evidence. This development has often taken place without extending the programs. We were interested in exploring views about current content of midwifery education in Sweden with a focus on clinical competencies and the new research components. OBJECTIVE: to investigate views about Swedish midwifery education held by students prior to graduation and after 1 year of practice, and by experienced midwives and obstetricians, with special focus on clinical competency. DESIGN: nationwide surveys conducted between June 2007 and January 2008, and 1 year later (follow-up of students). METHODS: self-administered questionnaires completed by 171 (83%) students and 121 (59%) of these participants after 1 year of midwifery practice, and by 162 (54%) midwives and 108 (40%) obstetricians with at least 5 years of clinical experience. The responders were asked to assess predefined intrapartum competencies, which components of the education were allocated too little and too much time, and how well the education prepared for clinical practise overall. Content analysis of open-ended questions and descriptive analyses was used. FINDINGS: most students, midwives and obstetricians were 'very' or 'fairly' satisfied with how the education prepared midwives for clinical practice and 1.8%, 4.7% and 17.6%, respectively, were dissatisfied. About half of the obstetricians and one-third of the experienced midwives rated new midwives' ability to identify deviations from normal progress as low or lacking, compared with 10% of the students. A majority found that too little time, of the 60 weeks programme, was allocated to intrapartum care and medical complications and too much time to research and writing a minor thesis. KEY CONCLUSIONS: although few were dissatisfied with how midwifery education prepared for clinical practice in general, the majority of participants would have liked more time for medical complications, intrapartum care, and emergency situations, and less for research. These findings suggest that the balance between clinical competency and research, and how the research component is integrated into clinical knowledge, should be further discussed and evaluated. Also the discrepancy between the views of newly educated midwives and those of more experienced midwives and obstetricians need further investigation.

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