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Dr. Stoll's Current Projects

Supporting midwives, to provide high quality care to diverse populations -Implementing recommendations of the Sustainable Midwifery Taskforce

Canadian and international studies show that midwifery care, and especially case load midwifery (the model practiced in BC) meets the Triple Aims of health system improvement and is linked to good outcomes among general populations of childbearing people and those with social risk factors. The midwifery model of care focuses on patient autonomy, and puts the needs and preferences of childbearing people first. Scaling up access to patient-centered, high quality models of health care delivery is a provincial priority, yet only a small proportion of families can access midwifery care and the profession is facing numerous challenges that threaten its growth and sustainability. A study conducted by Stoll & Gallagher (2018) revealed that 40% of BC midwives have seriously considered leaving the profession in the 12 months preceding data collection and 1 in 10 were actively making plans to leave. One in five reported that it is unlikely they will still be practicing as midwives in 3 years. Burnout and high levels of stress are associated with poor physical and mental health, and impacts on quality of care. Midwives suggested many strategies to reduce stress, such as: a broadened scope, more off-call career opportunities, ability to bill for additional supports and services for clients with complex care needs and initiatives to reduce inter-professional conflict. Addressing these issues requires the collaboration of key stakeholders, to develop an action plan for sustainable midwifery practice.

In January 2019, we set up the Sustainable Midwifery Practice Taskforce, to identify solutions to occupational stress and burnout among BC midwives. The taskforce is informed by two years of data collection with BC midwives, and uses an appreciative inquiry framework. Taskforce members include both practising and non-practising midwives, representatives from the Midwives Association of BC and College of Midwives of BC, midwifery researchers and educators, and a midwifery student representative.

It is the goal of the taskforce to identify solutions to burnout and occupational stress without creating new problems or exacerbating old problems. We want to prioritize solutions that benefit all midwives, irrespective of where they work. We want to remember the midwives who left the profession because they could not go on and need to find ways to engage them in conversations about sustainable practice. The taskforce recognizes that there are points in a midwife’s life when burnout and stress are more acutely felt. Vulnerable time points are during school and the early years of practice, when midwives raise young children, experience critical incidents, and/or develop chronic health problems and/or disabilities. In other words, sustainable practice starts in school and we must recognize that midwives who experience the above need additional supports, to remain in the profession.

Over the past 12 months, the taskforce has conducted evidence reviews and developed collaborations with key partners in BC and across Canada. For example, we just published a scoping review of the prevalence of and factors associated with burnout in midwifery. A total of 1,034 articles were identified and reduced to 27 articles across 17 countries. Prevalence of burnout was highest among Australian, UK, Western Canadian and Senegalese midwives and lowest among Dutch and Norwegian midwives. We identified 26 factors that were significantly associated with burnout. The most commonly reported factors were: insufficient organizational support/ poor or stressful work environment/, non case-load/non-continuity models of care (such as hospital shift work), younger age, fewer years in practice, high workload, exposure to traumatic events, interpersonal conflict with colleagues/low recognition of midwives, low job/task satisfaction/non-midwifery work tasks and lack of support from family or colleagues. Many of these factors were also cited by BC midwives.

In January- March 2020, the taskforce will interview midwifery association leaders in all provinces and territories, to gather information about best practice models and existing and planned initiatives to promote sustainable practice.

The main output of the task force will be a detailed report about the process and work of the taskforce, and a comprehensive list of resources and actionable recommendations for individual midwives, clinics, midwifery organizations, health authorities and the Ministry of Health. We hope to have the report ready by June 2020 and are looking for funding to continue this important work. Several new projects have emerged from the taskforce, including a proposal to set up a midwifery mental health committee and to develop a province-wide peer support network for midwives and midwifery students who experience critical incidents/traumatic events, a subcommittee focused on strategies to promote student wellness and other follow up projects, e.g. examination of the changing profile of midwifery clients, using Perinatal Services BC data from 2000-2017, and focus groups with midwives from the Lower Mainland who serve clients with complex needs, to better understand the resources and supports midwives need to care for this population.

Dr. Stoll feels very privileged to serve as co-lead of the taskforce and hope to continue supporting the growth and sustainability of BC midwives, through research and collaborative knowledge translation.

Relevant publications

Stoll K & Gallagher J. (2019). A survey of burnout and intentions to leave the profession among Western Canadian midwives. Women & Birth. 32(4): e441-e449. PMID:30341004

Sidhu R, Su B, Shapiro K & Stoll K (2020). Exploring prevalence of and factors associated with Burnout in Midwifery: A Scoping Review. European Journal of Midwifery, 4(February).

Midwife-led education for young people about pregnancy and birth, to reduce fear and misconceptions

Between 2014-2019 Dr. Stoll led a national team of midwifery and nursing researchers who study birth attitudes and preferences among young people in 8 OECD countries; to understand how childbirth fear relates to preferences for obstetric interventions, and how best to educate young people about pregnancy and birth.

Dr. Stoll’s interest in understanding the attitudes of young people towards birth began in 2006, when the Division of Midwifery launched a survey, to collect data about attitudes and preferences towards pregnancy and birth among students at the University of British Columbia, Canada (n=3680). We published a paper in 2009, about reasons why young people would choose vaginal birth versus Cesarean section and for her dissertation research Dr. Stoll undertook an in-depth secondary analysis of data. During her postdoc, Dr. Stoll engaged a team of international collaborators, to study attitudes towards birth in eight high-income countries across four continents.

The team collected data from over 4500 young people around the world and published several papers (see below); four papers describing results for the entire dataset and six country-specific papers. We were able to demonstrate that lack of exposure to and less knowledge of birth is linked to increased fear. Fear, in turn, is linked to preferences for unnecessary interventions. This is important because obstetric interventions, like Cesarean sections are overused and linked to an increased risk of maternal and newborn morbidities and increased healthcare costs. Students from the US had the lowest preference for midwifery care and community birth options and the most positive views about obstetric technology and interventions, compared to students from Europe and New Zealand. Young adults who learned about birth through the media and via school-based programs exhibited the highest levels of fear and preferences for interventions.

These findings point to the importance of re-evaluating how young people learn about birth at school and to counteract negative media portrayals of birth. An innovative, four-hour midwife-led education program for school children in Germany has shown both to increase knowledge of birth and to decrease fears among 1000+ elementary school children. Our team is in the process of applying for funding, to adapt the German program and test the midwife-led education modules at 5 Vancouver schools, with the support of an interdisciplinary team of educators, researchers, midwives and public health experts.

See below list of articles about this project.

Bibliography

Stoll K, Downe S, Edmonds J, Gross MM, Malott A, McAra- Couper J, Sadler M, Thomson G and the ICAPP Study Team (2019). A survey of university students' preferences for midwifery care and community birth options in eight high-income countries (in press). Journal of Midwifery & Women’s Health.

Weeks F, Sadler M, Stoll K (2019). Preference for cesarean attitudes in a Chilean sample of young adults. Women & Birth. E-Pub ahead of print. PMID: 30992177

Stoll, K, Edmonds, J, Sadler M, Thomson, G, McAra- Couper J, Swift, E, Malott A, M.M. Gross, Streffing J, Downe, S, and the ICAPP Study Team (2018). A cross-country survey of attitudes toward childbirth technologies and interventions among university students. Women and Birth. Epub ahead of print. PMID: 30150150 

Stoll K, Hauck YL, Downe S, Payne D & Hall WA (2017). Preference for cesarean section in young nulligravid women in eight OECD countries and implications for reproductive health education. Reproductive Health, 14(1), 116. PMID: 28893291

Thomson G, Stoll K, Downe S & Hall W. Negative Impressions of Childbirth in a North-West England Student Population (2017). Journal of Psychosomatic Obstetrics & Gynecology, 38(1):37-44. PMID: 27578057

Swift EM, Gottfresdóttir H, Zoega, Gross MM & Stoll K. Opting for natural birth: A survey of birth intentions among young Icelandic women (2016). Journal of Sexual & Reproductive Healthcare, 11:41-46. PMID: 28159127

Stoll K, Hauck Y, Downe S, Edmonds J, Gross MM, Malott A, McNiven P, Swift E, Thomson G and Hall W (2016). Cross cultural development and psychometric evaluation of a measure to assess fear of childbirth prior to pregnancy. Journal of Sexual & Reproductive Healthcare, 8:49-54. PMID: 27179378

Hauck Y, Stoll K, Hall W & Downie J. (2016) Association between childbirth attitudes and fear on birth preferences of a future generation of Australian parents. Women and Birth ;29(6):511-517. PMID: 27233945

Stoll K, Edmonds J & Hall W (2015). Fear of childbirth and preference for Cesarean delivery among young American women before childbirth: A survey study. Birth, 42 (3); 270–276. PMID: 26104997

Edmonds JK, Cwiertniewicz T & Stoll K (2015). A survey of childbirth preferences and attitudes among young women prior to pregnancy. Journal of Perinatal Education, 24(2), 93-101.

Stoll K, Hall W, Carty E & Janssen P (2014). Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian university students. Midwifery, 30(3), 220-226. PMID: 23968778

Stoll K & Hall W (2013). Attitudes and Preferences of Young Women with Low and High Fear of Childbirth. Qualitative Health Research,23(11), 1495-1505. PMID: 24108088

Stoll K & Hall W (2013). Vicarious birth experiences and childbirth fear among young Canadian women. Perinatal Education, 22(4), 226-233. PMID: 24868135

Clemons J, Payne D, McAra-Couper J, Farry A, Garrett N, Swift E, Stoll K. Gaining insight from future mothers: A survey of attitudes and perspectives of childbirth. (Manuscript is complete, journal TBD)