Advancement and integration of midwifery competencies in supporting physiological birth and promoting the humanisation of the childbirth experience.

This doctoral thesis explores how midwifery competencies can be strengthened and implemented to support physiological birth and promote the humanisation of childbirth. It is structured around two complementary components: a synthesis of existing evidence on midwifery care and an empirical investigation of clinical practice within an Italian hospital setting. The first part of the research examines midwifery practices during the first and third stages of labour. A systematic review of qualitative studies identifies seven key components underpinning support for physiological labour: trust in the birth process, the woman–midwife relationship, protection of the environment, presence and patience, flexible interpretations of normality, preparation and management of expectations, and professional solidarity among midwives. A scoping review of third-stage care further outlines two theoretical frameworks and maps core practices for physiological placental birth, highlighting how midwives balance confidence in the natural process with vigilance in preventing postpartum haemorrhage. Building on these findings, the thesis includes the Italian translation and cultural validation of the Physiological Practices Observation tool (PPO_ITA), enabling systematic measurement of midwifery care. An observational descriptive study, conducted in collaboration with AUSL della Romagna, analysed 51 midwife–woman interactions using this tool, generating approximately 100–150 hours of data. Results indicate consistent support for physiological birth despite a highly medicalised context, particularly in care approach, environmental support, and early postnatal care. Greater adherence was observed among more experienced midwives, especially in emotional support and facilitation of decision-making. However, lower scores in shared decision-making suggest ongoing barriers to fully woman-centred care. Overall, the thesis underscores the critical role of midwives in preserving physiological processes and recommends strengthening continuity of care models, education, and organisational policies that prioritise relational, woman-centred practice.