Mapping barriers to midwives’ educational role in Cyprus guided by the Theoretical Domains Framework

ISSUE: The high caesarean section (C/S) rate in Cyprus (>60%) led to the formation of a National Committee to address this Public Health priority. Among WHO recommendations for C/S reduction are midwifery-led educational interventions; yet, medicalization of birth in Cyprus is curtailing the autonomous role of midwives. DESCRIPTION OF PROBLEM: While midwives could “make every contact count” during routine appointments, antenatal education (AE) is reduced to a formal activity within the antenatal class space with documented low attendance. This formative research mapped barriers to the educational role of Cypriot midwives guided by behaviour theory. A context-specific understanding is needed to shape an appropriate intervention and promote a common understanding among stakeholders. RESULTS: One in three midwives islandwide (N = 119, response: 34%) rated 83 determinants (from 1=more to 6=less problematic), guided by the Theoretical Domains Framework (TDF). “Beliefs about AE importance” (M = 5.57, SD = 0.96) and “Professional role” (M = 5.58, SD = 0.57) received the highest scores. Lack of organizational resources (M = 3.39, SD = 0.97), institutional and inter-professional support (M = 3.77, SD = 1.4) and acceptance (M = 4.25, SD = 0.85) were identified as problematic. While perceived capabilities and intentions were rated favourably, achieving “Goals” was difficult, mainly due to competing priorities (M = 3.86, SD = 0.84). Self-efficacy and behavioural control were lower among less experienced midwives (p < 0.01) and in the private sector (p = 0.08), which accounts for >70% of births. LESSONS: Beyond the antenatal class, AE is a ‘bad fit’ with routine practice. The phenomenon pertains to organizational arrangements but also norms and perceptions of other providers and service users. While current Healthcare reforms present prospects in re-defining the role of midwives, the educational role is not adequately supported or promoted given the limited number of visits and reimbursement restrictions imposed. KEY MESSAGES: • Barriers to routine antenatal education originate from an unsupportive system and socio-cultural norms which alienate midwives in an already medicalized environment. • This theory-driven formative study described the issue in behaviour terms in the context of shaping an intervention to strengthen the health education role of midwives.