**2. Underutilization of the advanced midwives who are autonomous practitioners**

Advanced midwives as one of the advanced nursing qualifications globally are the midwives who are trained to achieve elevated levels of universal quality maternal care. The level and utilisation of the achieved knowledge and skill by the advanced midwife is globally according to the expectations of practice from the specific country that is training the advanced nurse practitioner. Advanced midwives go through a higher level of training which gives them the elevated level of knowledge and skills to practice midwifery care with attributes such as effective people skills, thoughtfulness, self-reliance, clarity of thoughts, self-evaluation, and self-confidence with the ability to reflect and analyse observations and care given to pregnant women, birthing women and their babies, and post-births women and their families [6]. In the process of advanced midwifery training, it is mandatory that the achievement of the success in training are measured and assessed through competencies in direct patient care, collaboration with multidisciplinary team, consultation in managing elevated risk conditions, and leadership skills. Competences acquired include skilfulness in managing obstetric complications like shoulder dystocia, breech delivery, resuscitations of newborns, vacuum extractions, and interpretations of statistics in maternity healthcare services. The elevated level of competency, knowledge, and skills acquired during the advanced midwives training prepares them to play the pivotal role of being the backbone of the maternal healthcare services. However, there are barriers to using all this learned because there is lack of clear job description for the advanced midwives in the tertiary hospital setting to enable them to utilise them their acquired knowledge and skills. The possession of the advanced skills and advanced knowledge by advanced midwives from their training, put them in the crucial point of care as an autonomous practitioner who is equipped to vigilantly stays with the patient in the prolonged hours of duty shifts. For midwives to fully fulfil their duties, clear policies of dealing with the four crucial areas of care need to be developed or dealt with in the tertiary hospitals which will allow midwives to fully function according to their scope of practice. Lack of policies directing the full functioning of the advanced midwives in the crucial areas of care identified by the midwives are the leading course of midwives challenges in tertiary hospitals in performing professional duties in the following four areas: full function to quality patient care, full contribution to teaching, dealing with managerial roles, and dealing with the admission of patients [3]. The impact of underutilization of the possessed knowledge and skills are seen in the contribution of quality patient care, contribution in teaching, dealing with managerial roles, and dealing with the admission of patients which are shown in **Figure 1**.

#### **2.1 Underutilization impact in the contribution of quality patient care**

Midwives are professional practitioners who are expected to fully contribute to patient care by being with the patient continuously in the patient's stay in the hospital.

 **Figure 1.**  *Impact of underutilization of the advanced midwives who are autonomous practitioners.* 

The major expectations in that giving of care include using the full role in rendering patient clinical care, patient advocacy, leadership in maternity care, and role modelling partnership with the multidisciplinary team. However, there are stressful hindrances in using all these expectations due to a lack of proper clarification of the advanced midwives in tertiary hospital environments in countries. The stressful environmental challenges which are available in the maternity areas and affecting the maternal healthcare services births experiences were even picked up by the international federations of midwives, gynaecologists, and obstetricians [ 7 ]. The International Confederation of the Midwives (ICM) and the Federation of International Gynaecological Obstetrics (FIGO) has greater support of close teamwork and recognition of the interdisciplinary collaboration between obstetricians, other healthcare providers, and midwives in support of the woman in labour and partner, coming baby, and the family at large. In addition to that recognition, FIGO and ICM are working towards up-to-date guidelines which are midwifery enabling to the working environments.

 In the rendering of care, midwives are to take full responsibility for the monitoring of the quality care which is received by the patients including the evaluation of the patient condition and mostly with the condition of the coming baby. To perform that watching and evaluating a function, the midwife needs to practice the skill to remain knowledgeable and skilful. It is unfortunate for the advanced midwives in tertiary hospitals as the procedures are performed by the medical doctors due to the conditions of the patients who are hospitalised. The main challenge is that when it comes to planning care for the same patients the midwives are catering, when it comes

#### *The Environmental Impact on Advanced Midwives from Underutilization in Tertiary Hospital DOI: http://dx.doi.org/10.5772/intechopen.113186*

to the involvement in decision making there is lack of midwives' involvement in the multidisciplinary team. Lack of midwives' involvement in planning and decisionmaking in the care given to patients pushes the midwives to their cocoon space which leads to defensive midwifery practice which does not improve the maternal healthcare services. The defensive midwifery practice is one of just conducting doctors' orders and prescriptions without evaluation and documenting own performance which is psychologically stressful to the midwives. Tertiary hospitals are full of medical doctors in training who still need guidance in their maternity practices. However, due to a lack of structured communication and clear role descriptions of the advanced midwives, even the training obstetricians are taking decisions without discussing the patient with the midwives. Teamwork and full use of all team members is the key to saving patients' lives which is the main aims of tertiary hospital care. However, there are studies which exposed that the functionality of the multidisciplinary team lacks full involvement of the other team members like advanced midwives which leads to the underutilization of their knowledge and skills. The main purpose of multidisciplinary care is to enable all team members to consensually reach an agreement on the type of care to be provided to the patients.

Midwives do understand that in tertiary hospitals the responsibility of care has grey area for sharing, and that doctors take full responsibility. However, having been equipped with knowledge and skills which is not practiced make them a scapegoat for the malpractices in the tertiary hospitals as one of the midwives' roles is to take a lead in advocating for the pregnant women, unborn babies, and the newborns under their care in the multidisciplinary team. Midwives are more productive in the rendering of care in the work environment which enables them to serve with a reflection of their personal and professional philosophies as midwives. The midwife's professional philosophy is shown when they are collaborating with colleagues who have the descent work ethics, when they practice their passion of advocating for pregnant women, babies, and family members under their care. In the healthcare system, nurses and midwives are the centre in the provision of the autonomous care which reflect in the collaboration of the multidisciplinary groups of community in different settings of care. The continuous stay of the midwives with the maternity patients requires them to be spokespersons or advocators for those who cannot talk like newborns, terribly ill women, the scared and the shy patients who cannot talk for themselves in the multidisciplinary team care. The advocacy role of the nurse and the midwife are the key roles in the management of the maternal healthcare system [8]. In tertiary hospitals midwife's advocacy role if fully utilised, can save patients' lives, and prevent unnecessary complications which lead to litigations. In case of loss of life and complications there is always increased level of self-blame to midwives as they are equipped with knowledge and skills for caring and for advocacy in their midwifery training. The contributory factor of blocked advocacy is being belittled by medical doctors, lack of respect from doctors when it comes to taking midwives advice and involving midwives in planning patient's care [3]. Lack of the use of the multidisciplinary team knowledge and skill in supplying quality care contributes to midwives' psychological stresses in tertiary healthcare services.

#### **2.2 Underutilization impact in teaching contributions**

Teaching function is one of the midwives' professional mandates. Tertiary hospitals are full of different health professional students which include medical doctors (registrars) and nurses. Knowledge sharing is a way of strengthening the rendering of quality care as skills and knowledge are shared within diverse levels of the multidisciplinary teams.

The advanced midwives are proud in sharing their skills of effective continuity of care, diagnostic accuracy, reduction of mortality rate by early detection of complications, leading the innovative service delivery, including the provision of care, which is safe and satisfactory to patients to patients. There are hinderances in the work environment which makes it difficult for knowledge sharing. Lack of human and material resources are mostly the major obstacles that prevent the smooth running of the teaching contribution part. Knowledge and skills are easily shared through the demonstration of expected quality care in the work environment. Lack of equipment contribute to sharing of skills which compromises patient care. There is a distinct lack of essential resources like delivery packs, sanitary pads, and suturing materials in the birthing units which forces midwives to compromise patient care. Through teaching the midwives are encouraged to study to adjust and cope with the different innovations of care. There are researchers who recommend the improvement of quality care and clinical education in maternal healthcare globally through the introduction of skilful midwives in clinical sites at the tertiary-levels of care hospitals with the enormous number of students [9].

Midwives lose their skills and Knowledge by working with enormous number of patients without the necessary equipment and that course stress as wrong equipment's are used for improvising the proper tools of traits. Teaching of junior staff stimulates midwives to more reading, to be innovative, and to be up to date with all clinical care needed for critically ill patients. Midwives' job satisfaction comes from providing care that is acceptable and can easily be shared with other health professionals in multidisciplinary teams. A shortage of staff with the influx of patients makes the tertiary environment impossible for the scheduled teachings by the midwives. Sharing and provision of quality patient care to women and their families are rated high in safe midwifery practices [10].

Medical and nursing students are distributed to the maternity units to reinforce and practice the skills which have been shown to them at the skills lab in nursing colleges and universities. Lack of the essential tools of traits fails the midwives' teachings and can also lead to litigations which midwives fear. Demonstrating care to medical and nursing students with improvised tools of traits reflects the incapability of keeping professional legacy, hence midwives feel discouraged to teach as students will refer to them as not teaching according to the norms and standards of the universities and colleges. Patient care without sharing knowledge and skills affects the midwives psychologically as it reduces the knowledge, skills, and confidence in midwifery practice.

#### **2.3 Underutilization impact in dealing with managerial issues**

Managerial issues are more challenging to manage in tertiary hospitals as they deviate midwives' attention from holistic patient care. The main managerial issues which are a challenge are dealing with both human resource and non-human resource issues. Managerial challenges are depicted by incomplete documentation of the care rendered as the undocumented information in maternal healthcare services reflects the unprovided patient care. The shortage of obstetricians and midwives is a global challenge which affects patient care in all levels of care in maternity healthcare services. Globally the midwives outnumber the obstetrician's number which forces midwives to perform the obstetrician's duty in case of emergencies when doctors are busy with obstetric emergency cases in theatre or in the wards [11]. However, advanced midwives are faced with challenges of the unspecified job descriptions

#### *The Environmental Impact on Advanced Midwives from Underutilization in Tertiary Hospital DOI: http://dx.doi.org/10.5772/intechopen.113186*

in the upset of the doctors in the identifiable grey areas of procedures that can be performed by the doctors or the midwives. In the case of loss of life or complication, the blame will always be shifted to the midwives as they are the first contact with patients and continue monitoring the patient throughout the patient stay in the hospital. Midwives do render holistic care to maternity patients, but with a high influx of patients, midwives sometimes end up with challenges of lack of time to make clear documentation of the rendered care.

Most challenges are caused by the shortage as there is always a gap in unrendered care as there are not enough midwives who can cater for the high volume of patients in tertiary hospitals. The high volume of patients is from the non-stipulated global midwife-patient ratio in tertiary hospitals. There is also an identified lack of clinical care and support in clinical practice from nursing leadership to the healthcare providers. Midwives also need support and mentorship from leadership in the management of complicated patient care. In the current technological era where patients get more information on internet, midwives need more support from senior managers and researchers to give them the courage to implement the new birthing positions and pain relief methods. Midwives suggest on the additional midwives in the clinical areas and to be trained in different skills as a way of showing support on their midwifery practices. Lack of or minimal support and mentoring from leadership in maternal healthcare services contribute to substandard care as midwives are scared to implement the acquired skills as in case of complications, they will not be supported by the nursing managers without being blamed for practicing doctors' skills in tertiary hospitals. Hence advanced midwives end up performing routine care which does not stimulate their thinking capacity, and compromises patient care in tertiary hospitals. Lack of or poor trust among midwives, obstetricians, paediatricians, and hospital leadership increases the stress level in the tertiary maternal healthcare environment. Staffing of the maternal health services affect the care rendered to women, babies, and their families in a negative way as it causes adverse effects in their lives. Shortage of staff has been observed and identified by FIGO's Safe Motherhood and Newborn Health Committee which came up with the proposal of having standards staffing policy setting which starts from the labour wards, and the staffing to take into consideration the volume of deliveries in the area, professional skill mix among the midwives and the obstetricians. The same committee also stressed the issue of the shift leader as the key role player in the management of shortage [12].

In that environment with gross shortages of obstetricians, paediatricians, and midwives, there is also a big challenge of non-human resource. Tools of traits are also a big challenge to maternity healthcare providers. There shortage of suitable machines for monitoring women in labour, including birthing materials. Midwives do improvise to save lives and those are the things which make them fall through the net as it increases sepsis in the maternal healthcare services. Poor or lack of patient referral systems in the countries which lead to low-risk cases landing in tertiary hospitals.

#### **2.4 Underutilization impact in dealing with admission of patients**

Advanced midwives are mandated to screen and manage maternity patients at the lower levels of care like MOU and primary healthcare services. However, due to a lack of proper coordination of maternal healthcare services, midwives find themselves managing the unbooked and self-referrals in the tertiary hospitals. The main challenge with the unbooked patients is that they miss the opportunity to be screened and managed for complications during antenatal period. Hence, they usually come in tertiary hospitals with complications which exposes them to losing their unborn

babies or losing their lives. Sometimes complications do happen in the process of transferring patients between the primary healthcare services and the tertiary hospitals as the transport for transferring patients do delay or not equipped with tools of traits or adequately trained staff for managing complications. Loss of life in such circumstances causes a lot of psychological stress to healthcare providers.
