Development and preliminary testing of the WCCS-MSR is an important undertaking to describe and measure critical aspects of woman-centred midwifery practice. Woman-centred care underpins midwifery philosophy and is an integral component of the midwifery landscape in Australia, New Zealand, and many other countries. Both midwives and women acknowledge the importance of woman-centred care, and the trusting relationship established between the midwife, the woman, and her significant others . In the current study, a relatively large sample of midwives participated, giving confidence to the generalisability of results. Compared to workforce data in Australia and New Zealand, [33, 34], participating midwives were similar for age and education, although over- represented by Australian midwives working in a caseload model of care.
Factor 1 “Meets the woman’s unique needs” consists of 12 items with good internal consistency. The mean score of 73.9 out of a possible 84 reflects a high level of agreement. These items reflect a midwife’s ability to adapt to the environment to meet a woman’s needs (items 73 and 75), promote her dignity (item 76) and enhance her wellness (items 68 and 70). Fahy, Foureur  established the midwifery theory “Birth Territory”, suggesting that when midwives use midwifery guardianship, they create the ideal territory for women to birth, that enhances their normal physiology, enables them to feel satisfied and to transition seamlessly into the postnatal period. Creating a safe environment for the woman is crucial to enhance informed decision-making so that she feels empowered and supported [15, 16]. Providing a respectful, calm and safe birthing space for the woman to welcome her newborn into a safe birth space has been found to enhance the bonding relationship between the woman and her baby . This factor also considered the importance of inclusion of the woman’s significant others (item 65) as working in partnership with the woman that means being inclusive of her partner and support people .
Factor 2 “Balances the woman’s needs within the context of the maternity service” speaks to the inherent tensions experienced by midwives as they advocate for the needs of women when working in the maternity system. The mean score of 26.6 out of a possible 35 reflects a moderate level of agreement. This factor may need further testing due to its moderate to low internal consistency. In general, this factor focuses on meeting the individual needs of women within the context of a maternity service that is driven by a standardised approach (items 26 and 55 for example) which is often risk-adverse. Walsh  refers to standard maternity care as an “assembly line” shaped by industrial models. This tension between standardisation and individualisation has also been recognised by health sociologists  and at the centre of calls for an approach to humanise childbirth . This tension may relate to dilemmas in loyalty and professional socialisation, contributing to friction between the woman, the midwife, and other practitioners. The low internal consistency of this factor may reflect diversity in respondents’ educational qualifications and commitment life-long learning, education, reflection, and self-awareness though this was not examined in this study. Low internal consistency may be a reflection of the small number of items; low interrelatedness between test items, or the possibility that the items are measuring more than one latent variable. The relatively lower mean score demonstrated for items in this factor may also reflect the challenges of providing woman centred care within organisational contexts.
Factor 3 refers to “Ensuring midwifery philosophy underpins practice within the context of the maternity service” and has 4 items which were all worded negatively. The mean score of 17.4 out of a possible 28 reflects a modest level of agreement. This factor may also need to be reconsidered for further testing due to low internal consistency. The factor includes items focusing on a personalised approach to care (items 51 and 56), midwifery competence (item 33) and the influence of clinical guidelines (item 72). A personalised approach has been recognised by midwives as an important element of woman-centred care  although midwives must balance sometimes competing interests including organisational and interprofessional issues . Another study also showed that midwives’ views have been strongly interwoven with advocacy for the woman, to ensure her choices are being met and promoting self-determination in order to support the woman’s accomplishment of her goals and choices, irrespective of the care setting . Maintaining competence across all areas of midwifery practice may promote a personalised approach within these competing interests . Like factor 2, the relatively lower mean score demonstrated for items in this factor may also reflect the challenges of providing woman centred care within organisational contexts.
Factor 4 “Working collaboratively for evidence-based practice” describes the collaborative nature of midwives’ work and the importance of evidence-based practice (EBP). The mean score of 41.6 out of a possible 49 reflects a high level of agreement. The seven items describe woman-centred midwifery practice as making decisions in collaboration with women (item 25); seeking feedback from women (item 37); and providing a professional opinion even if other health care professionals don’t agree (item 34). Woman-centred care is ascribed to mutual responsibility and participation that is demonstrated by interdependent collaboration, consultation and co-operation between the woman and the midwife . Midwives as advocates for the women in their care, often face opposition from other health professionals including obstetricians and other midwives . This factor seems to speak to confidence as knowing where to find evidence to inform practice, understanding professional boundaries, proffering one’s own professional opinion and challenging others, are characteristics of a confident midwife. Midwifery confidence has been linked to autonomy with workplace culture and midwifery colleagues being some of the most influential factors .
Factor 5 refers to “Working in Partnership with Women”. The mean score of 77.6 out of a possible 84 reflects a high level of agreement. This 12-item scale includes items related to informed choice and participation in health care decisions (items 27 and 52), inclusion of the woman’s significant others (items 62 and 49), and an approach to care that considers the woman holistically (items 48 and 50). The importance of respecting women’s autonomy in childbirth has long been understood and includes encouraging participation in health care decisions which is central to the partnership model of midwifery . Involvement in decision making is associated with a greater sense of safety in childbirth and the World Health Organization (2016) has identified respect and autonomy as key features of quality maternity care.
Reliable and valid measurement of woman-centred care has several applications. The WCCS-MSR will be useful in contemporary practice to not only highlight best practice by midwives but identify areas in need of improvement. Repeating the tool over time could be included in professional development and as a reliable indicator of quality care. The WCCS-MSR could be used in pre-registration midwifery programs to make the elements of woman-centred care explicit to students, enable self-assessment, as well as identify areas for improvement. Woman-centred care is a universal principle and as such the WCCS-SR has applicability to all English-speaking midwives in any maternity care context.
There are several limitations associated with this preliminary study. Although a relatively large sample was recruited, 81 respondents (20%) commenced but did not complete the survey introducing possible response bias. Consequently, respondents may systematically differ from those who withdrew or did not respond. Additionally, the number of midwives invited to participate through professional networks and Facebook could not be determined, therefore a true response rate could not be calculated. The inability to contact respondents also precluded test–retest reliability being assessed. Generalisability may be limited as this survey was only distributed in Australia and New Zealand. The recruited sample was over-represented by Australian midwives working in a caseload model of care. The over representation may reflect the interest of caseload midwives in woman-centred care, introducing possible bias. Although the tool development team were geographically diverse, the overall network may have been homogenous thereby limiting the reach to different sectors of the midwifery community. Concurrent validity could not be established as the research team were unable to locate a similar tool in the literature. To this point, the topic has been primarily investigated through qualitative studies.
This is the first tool of its kind to enable midwives to undertake self-appraisal of their woman-centred practices. It is envisaged that the tool will be useful for reflective practice by midwives as they consider ways to develop skills and ways of caring that are aligned with professional philosophy and standards.
The team undertook rigorous tool development processes involving an analysis of systematic review findings; generation of a large pool of items; consultation with a group of experts; and piloting with a large sample of practicing midwives. WCCS-MSR items loaded on a five-factor solution which accounted for over 48% of the variance. While this proportion is acceptable, future research should aim to increase the variance accounted for, by refining existing items and adding new items where necessary. Various forms of validity testing reduced the number of items from 98 to 40 but other items that accurately reflect woman-centred midwifery care need to be included and tested. Two factors emerged with low internal consistency and further consideration of these items and testing is required. This may be achieved by validating this instrument with a larger and more diverse sample.
In this study, elements of validity were established (face, content, and construct) but further testing is required. The next step would be to test the WCCS-SR with another large diverse sample of midwives and include standardized tools that aim to measure similar (concurrent validity); different (discriminatory validity); or other constructs that predict woman-centred care. The total mean WCCS-MSR score of 237.9 out of a possible 280 reflects a high level of agreement on items. Future research could examine the internal structure of the WCCS-MSR using Rasch Measurement Theory [47, 48]. This analysis could inspect the response format, item fit, and differential item functioning to further validate the tool. Future distribution to other countries outside Australia and New Zealand is recommended.