Clinical judgement processes of midwives engaged in in-hospital midwife-led births: a qualitative exploratory study

Japan is facing a significant shortage of obstetricians, particularly in rural areas. To address this problem, the government has been promoting in-hospital midwife-led care to shift certain responsibilities from obstetricians to midwives. The essence of in-hospital midwife-led care lies in the midwives’ judgement and effective practices. This study aimed to understand the clinical judgement process of midwives who provide in-hospital midwife-led births. This study employed a qualitative exploratory design using participant observation and think-aloud with nine midwives across three hospitals in Japan. Observations focused on midwives’ clinical behaviours during the first stage of birth. The midwives verbalised their clinical judgements as soon as possible. When they were unable to verbalise, we asked them to describe how they perceived the labouring woman and the type of care or actions they considered engaging in. Data from participant observations and linguistic data gathered during think-aloud were recorded on video. We analysed the data by combining participant observation with clinical judgement using content analysis. We extracted seven key categories that characterise the clinical judgement processes for midwives during delivery: (1) Predicting the condition of labouring women and determining the initial direction of care upon taking responsibility; (2) Gathering information by asking questions in different ways to identify minor changes in labouring women’s condition; (3) Examining the cause of the problem from available information to uncover and determine the root cause; (4) Predicting birth progress and determining care based on information beyond internal examinations; (5) Instantly modifying the direction of care based on labouring women’s condition; (6) Determining what care should be provided immediately based on predictions of birth progression; and (7) Providing continuous care based on labouring women’s responses to care. Midwives engaged in in-hospital midwife-led births demonstrated heightened sensitivity to even subtle changes during delivery. They gathered nuanced information through the five senses to predict the progress of birth and provide care. They modified the direction of their care based on the women’s responses and provided the best care for the women on a continuous basis.