Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students' perspectives.

BACKGROUND: Internationally, midwifery education and maternity services are evolving to promote midwifery continuity of care. It is unclear whether current Australian midwifery education programs are graduating a midwifery workforce prepared and motivated to work in this way. AIM: To discover how well midwifery students in Australia feel they have been prepared and motivated to work in midwifery continuity of care when they enter practice. METHODS: A pragmatist approach was used. Participants were final year midwifery students at one Australian university participating in the Midwifery Student Evaluation of Practice (MidSTEP) project over three consecutive years. Descriptive analysis of selected scaled and free text responses was undertaken to ascertain how students' clinical practice experiences had influenced their learning, development and career aspirations. RESULTS: Exposure to midwifery continuity of care had profound impact on students' learning, enabling them to provide woman-centred midwifery care whilst increasing confidence and preparedness for practice. The majority were motivated to work in midwifery continuity of care upon graduation. A small minority of participants felt unprepared to work in midwifery continuity of care, attributing this to their family commitments, a sense of needing more experience or unsupportive workplace cultures. SUMMARY: Midwifery continuity of care experiences are highly valued by midwifery students and positively influence confidence, preparation and motivation for beginning practice. It is necessary to review education standards to ensure quality, consistency, and adequacy of these experiences throughout pre-registration midwifery education. This will assist in generating a midwifery workforce prepared and motivated to deliver the goals of maternity service reform.

The impact of pre-registration education on the motivation and preparation of midwifery students to work in continuity of midwifery care: An integrative review.

Access to continuity of midwifery care (CoMC) models in Australia is increasing but the capacity of the emerging midwifery workforce to provide this care remains largely unknown. The aim of this integrative literature review is to discover how well pre-registration midwifery education prepares and motivates Australian midwifery students to work in CoMC models when they enter practice. Following title review of 432 papers, removal of duplicates and review against the inclusion and exclusion criteria, nine papers were included for review. The results show that access to CoMC is a crucial component of midwifery education, equipping students with knowledge, skills, confidence and motivation to work in this way upon graduation. Existing methods of program delivery and institutional structures often present students with challenges that detract from the value of their CoMC experiences. A focus on CoMC placement - particularly with a continuity of midwifery mentor - may motivate graduates to work in this model of care. This strategy is recommended to better align Australian midwifery education with maternity care reform.

Enhancing Connectedness Through Peer Training for Community-Dwelling Older People: A Person Centred Approach.

Social interaction and connectedness is important to the mental health and wellbeing of older people. The aim of this research study was to facilitate and increase opportunities for social connectedness for older people living in regional areas through the use of technology training. Weekly technology training sessions were conducted at a Seniors Citizen's Club with a peer trainer (an experienced, retired computer teacher) and sessions were attended not only by the six study participants, but also by other club members, with up to 15 club members participating in sessions. Data analysis involved all documents generated by the project, including the individual interviews, researcher observations of training sessions, reports from the peer trainer and weekly diaries maintained by participants. Findings demonstrated that computer training at the Senior Citizens Club helped participants build group cohesion and to form tiered connections with partners, family, and friends with whom they no longer live. When the trainer is seen as a peer, and training is person-centred, older people are more receptive to learning, exploring, and experimenting with technology. Although only six people were involved in the in-depth evaluation part of the study, voluntary training with the trainer in the absence of any funding continues even to this present time. The outcome of this research reinforces the potential for technology facilitated tiered connectivity to enhance the quality of life for older people living in regional and rural Australia.

Nursing and climate change: An emerging connection.

Awareness of the importance of climate change to public health has been growing. Calls for health professionals, including nurses, to take action to prepare for, and mitigate, climate change have been coming from a number of credible sources. This paper will assist nurses to recognise the health consequences of climate change, to generate and disseminate knowledge about these health consequences, to be active in mitigating emissions locally and within their organisations and to advocate and have input into policy processes. It is valuable for nurses to understand the health co-benefits of emission mitigation and the current health costs of fossil fuels. As advocates for evidence-based public health initiatives, nurses have a role to play in communicating to the public and to policy makers accurate information, including about the health costs of fossil fuel policies and the affordability of renewable energy technologies.

Barriers and facilitators to accessing skilled birth attendants in Afar region, Ethiopia.

OBJECTIVE: to explore barriers and facilitators that enable women to access skilled birth attendance in Afar Region, Ethiopia. DESIGN: researchers used a Key Informant Research approach (KIR), whereby Health Extension Workers participated in an intensive training workshop and conducted interviews with Afar women in their communities. Data was also collected from health-care workers through questionnaires, interviews and focus groups. PARTICIPANTS: fourteen health extension workers were key informants and interviewers; 33 women and eight other health-care workers with a range of experience in caring for Afar childbearing women provided data as individuals and in focus groups. FINDINGS: participants identified friendly service, female skilled birth attendants (SBA) and the introduction of the ambulance service as facilitators to SBA. There are many barriers to accessing SBA, including women׳s low status and restricted opportunities for decision making, lack of confidence in health-care facilities, long distances, cost, domestic workload, and traditional practices which include a preference for birthing at home with a traditional birth attendant. KEY CONCLUSIONS: many Afar men and women expressed a lack of confidence in the services provided at health-care facilities which impacts on skilled birth attendance utilisation. IMPLICATIONS FOR PRACTICE: ambulance services that are free of charge to women are effective as a means to transfer women to a hospital for emergency care if required and expansion of ambulance services would be a powerful facilitator to increasing institutional birth. Skilled birth attendants working in institutions need to ensure their practice is culturally, physically and emotionally safe if more Afar women are to accept their midwifery care. Adequate equipping and staffing of institutions providing emergency obstetric and newborn care will assist in improving community perceptions of these services. Most importantly, mutual respect and collaboration between traditional birth attendants (Afar women׳s preferred caregiver), health extension workers and skilled birth attendants will help ensure timely consultation and referral and reduce delay for women if they require emergency maternity care.

Childbearing traditions of Indian women at home and abroad: An integrative literature review.

BACKGROUND: The percentage of overseas-born mothers giving birth in Australia has increased to 31.5% in 2012 and Indian women represent 10% (the highest proportion). It is important for midwives in Australia to be aware of the childbearing traditions of Indian women and how these influence Indian women birthing in Australia. AIM: To explore childbearing practices in India and Indian women's experience of giving birth abroad; and to discuss the relevant findings for midwives working with Indian women in Australia. METHOD: An integrative literature review was employed. 32 items, including 18 original research articles were thematically reviewed to identify commonly occurring themes relating to Indian women's childbearing traditions. FINDINGS: Five themes relating to traditional childbearing practices of women birthing in India were identified. These themes included diversity and disparity; social context of childbirth and marriage; diet based on Ayurveda; pollution theory and confinement; and finally, rituals and customs. CONCLUSION: Indian women giving birth abroad and by implication in Australia experience a transition to motherhood in a new culture. While adjusting to motherhood, they are also negotiating between their old and new cultural identities. To provide culturally safe care, it is essential that midwives reflect on their own culture while exploring what traditions are important for Indian women.

'Two dead frankfurts and a blob of sauce': the serendipity of receiving nutrition and hydration in Australian residential aged care.

BACKGROUND: This paper explores the serendipity of residents accessing adequate food and fluids in aged care facilities. It draws on the findings of two discrete but interrelated research projects conducted in 2009 and 2011 relating to the experience of living in, or having a friend or family member living in, residential aged care. METHODS: Participants were recruited through media outlets. Indepth interviews with participants were audiotaped, transcribed verbatim and thematically analysed. FINDINGS: This paper discusses a theme that was iterated by participants in both projects that is, the difficulty residents in aged care facilities experienced in receiving adequate and acceptable food and fluids. Unacceptable dining room experiences, poor quality food and excessive food hygiene regulations contributed to iatrogenic malnutrition and dehydration. Implications for staffing, clinical supervision, education of carers and the impact of negative attitudes to older people are discussed. CONCLUSION: The inability of dependent residents in aged care facilities to receive adequate nourishment and hydration impacts on their health and their rights as a resident, and is an ongoing issue in Australian residential aged care.

Barriers to providing school-based health care: international case comparisons.

BACKGROUND: This article reports on an international collaborative study which compared school-based health care in the United States of America, Canada and Australia. METHOD: Tri-nation school-based health care was compared and contrasted through the utilisation of a series of interpretive case studies. Grounded theory approaches informed the data analysis and reporting processes. FINDINGS: Unlike the US, Canadian and Australian school students rarely have access to school-based health care on site. All three nations face structural, cultural and societal barriers, often related to limited resources which limit the effectiveness of school-based health care. DISCUSSION: The benefits of school-based health care and providing comprehensive services through schools can include healthier children, better learning, healthier parents, and healthier communities. Unfortunately, based on our research, comprehensive school health services have not been adequately implemented in the US, Canada or Australia. IMPLICATIONS FOR PRACTICE: Given the findings of this study, increased comprehensive school-based health services are urgently needed in the US, Canada and Australia.

Pregnancy as public property: the experience of couples following diagnosis of a foetal anomaly.

BACKGROUND: Pregnant women find themselves subject to comments and questions from people in public areas. Normally, becoming 'public property' is considered friendly and is relatively easy for pregnant women to deal with. However, following diagnosis of a foetal anomaly, the experience of being public property can exacerbate the emotional turmoil experienced by couples. Original research question: What is the experience of couples who continue pregnancy following the diagnosis of a foetal anomaly? METHOD: The study used an interpretive design informed by Merleau-Ponty and this paper reports on a subset of findings. Thirty-one interviews with pregnant women and their partners were undertaken following the diagnosis of a serious or lethal foetal anomaly. Women were between 25 and 38 weeks gestation at the time of their first interview. The non-directive interviews were audio-taped, transcribed verbatim and the transcripts were thematically analysed. FINDINGS: A prominent theme that emerged during data analysis was that pregnancy is embodied therefore physically evident and 'public'. Women found it difficult to deal with being public property when the foetus had a serious or lethal anomaly. Some women avoided social situations; others did not disclose the foetal condition but gave minimal or avoidant answers to minimise distress to themselves and others. The male participants were not visibly pregnant and they could continue life in public without being subject to the public's gaze, but they were very aware and concerned about its impact on their partner. CONCLUSION: The public tend to assume that pregnancy is normal and will produce a healthy baby. This becomes problematic for women who have a foetus with an anomaly. Women use strategies to help them cope with becoming public property during pregnancy. Midwives can play an important role in reducing the negative consequences of a woman becoming public property following the diagnosis of a foetal anomaly.

The feasibility of caseload midwifery in rural Australia: a literature review.

BACKGROUND: Caseload midwifery is a continuity of care(r) model being implemented in an increasing number of Australian maternity settings. Question for review: is caseload midwifery a feasible model for introducing into the rural Australian context? METHOD: Integrative literature review. FINDINGS: Four main categories were identified and these include the evidence for caseload midwifery; applicability to the rural context; experiences of registered and student midwives and implementation of caseload midwifery models. CONCLUSION: There is evidence to support caseload midwifery and its implementation in the rural setting. However, literature to date is limited by small participant size and possible selection bias. Further research, including rural midwives' expectations and experience of caseload midwifery may lead to improved sustainability of midwifery care for rural Australian women.

Forced into exile: the traumatising impact of rural aged care service inaccessibility.

INTRODUCTION: The shortage of residential aged care places is especially acute in rural areas and this results in many older people who live in these areas being forced to leave their home communities to access care in distant communities. This article reports on one aspect of a larger study that explored family and caring community members' experiences when someone they cared for needed to access residential aged care away from their rural communities. METHODS: This qualitative research project, informed by phenomenology, was conducted in rural communities of New South Wales (NSW), Australia. Participants were recruited from media coverage of the proposed research. Indepth interviews were conducted, audiotaped and transcribed. Thematic analysis was undertaken by two researchers independently analysing the themes and then cross-checking these to ensure their strength. RESULTS: The 21 interviews conducted revealed that inaccessibility of residential aged care places caused many to experience loss, loneliness and a sense of social disconnectedness. The affected rural older person is exiled from their home community only to return to be buried. There are implications for the family and the rural community who are distanced by kilometres, transport and finances and, more significantly, by the emotional ties that bind families, friends and communities. CONCLUSION: The participants whose experiences were explored in this article described a sense of being in exile when residential aged care services are inaccessible in their local communities. The sense of exile is felt not only by the person moving away but also by their family, friends and neighbours. For this reason, rural residential aged care service delivery should be based on the identified needs of the older person and those who love and care for them.

Learning lessons from a traditional midwifery workforce in western Kenya.

OBJECTIVE: To learn lessons from a traditional midwifery workforce in Western Kenya. DESIGN: With the assistance of an interpreter, qualitative data was collected during in-depth individual and group interviews with traditional midwives. English components of the interviews were transcribed verbatim and the data thematically analysed. SETTING: A rural, economically disadvantaged area of Western Kenya. PARTICIPANTS: 84 participants who practise as traditional midwives. FINDINGS: It was common for these traditional midwives to believe they had received a spiritual gift which enabled them to learn the skills required from another midwife, often but not always their mother. The participants commenced their midwifery practice by learning through an apprenticeship or mentoring model but they anticipated their learning to be lifelong. Lifelong learning occurred through experiential reflection and reciprocal learning from each other. Learning in colleges, hospitals and through seminars facilitated by non-government organisations was also desired and esteemed by the participants but considered a secondary, though more authoritative source of learning. KEY CONCLUSIONS: The primary learning strategies used by the participants enabled them to have confidence in physiological birth; birthing women; and their own skills as traditional midwives. IMPLICATIONS FOR PRACTICE: Learning from women and continued professional reflection are ways of learning for midwives that may increase their confidence in women, birthing and their midwifery skills. These attributes are essential for midwives, regardless of their workforce context.

The experience of being a traditional midwife: living and working in relationship with women.

INTRODUCTION: The purpose of this project was to learn from traditional midwives about their experience of practicing in an area of rural Kenya. METHODS: This qualitative, service-based research project used a simple exploratory and descriptive design. Data were collected through in-depth interviews and fieldwork notes taken during and immediately after the interviews with 84 traditional midwives. Data were thematically analyzed and themes identified through paired-author consensus. Exemplars using the participants' translated words were used for analysis and presentation purposes. RESULTS: In being humble, patient, and kind, the traditional midwives used their relationships with women to create an enabling, calm, and physiologically sound intrapartum environment. DISCUSSION: Traditional midwives provide a valuable service to women in this area of Kenya at a time when their role is being increasingly devalued by global health agencies. We recommend a redirection of global policy from one that esteems only professional caregivers to one that recognizes the potential value of traditional midwives and supports them through sustainable, evidence-based education and resourcing.

Australian Aboriginal kinship: a means to enhance maternal well-being.

BACKGROUND: The relocation of women from their rural communities to birth in a centralised hospital is becoming increasingly common as maternity units close in rural areas of Australia. The significance for Aboriginal women when they are denied the support of kin around the time of birth but have that support re-established postnatally is explored. METHODS: This paper gathered data from multiple sources including in-depth interviews with three Aboriginal mothers and one partner; observational field notes; and during debriefing, the knowledge and experience of an Aboriginal midwife. Thematic analysis was utilised to both explore and critique the collected data. FINDINGS AND DISCUSSION: Aboriginal women are particularly disadvantaged by maternity unit closures in rural areas of the south eastern Australian state of New South Wales (NSW). However, contrary to the expectation that this would result in postnatal mental health problems, the support the Aboriginal participants in this study received from kin may have had a mediating effect which enhanced their well-being and possibly prevented mental ill health. RECOMMENDATIONS: Recommendations relate to strategies and policies that have the potential to increase community governance and feelings of cultural safety for Aboriginal childbearing women living in rural areas. CONCLUSION: While the practice of forcing Aboriginal women to relocate around the time of birth has a negative impact on perinatal health outcomes, kinship support may be a mediating factor.

Cultural safety and its importance for Australian midwifery practice.

Cultural safety is an important concept in health care that originated in Aotearoa (New Zealand) to address Maori consumer dissatisfaction with health care. In Australia and internationally, midwives are now expected to provide culturally safe midwifery care to all women. Historically, Australia has received large numbers of immigrants from the United Kingdom, European countries and the Middle East. There have also been refugees and immigrants from South-East Asia, and most recently, from Africa. Australia continues to become more culturally diverse and yet to date no studies have explored the application of cultural safety in Australian midwifery practice. This paper explores how cultural safety has evolved from cultural awareness and cultural sensitivity. It examines the importance of cultural safety in nursing and midwifery practice. Finally, it explores the literature to determine how midwives can apply the concept of cultural safety to ensure safe and woman centred care.

The experience of being a traditional midwife: relationships with skilled birth attendants.

INTRODUCTION: This article focuses on an unexpected finding of a research project which explored the experience of being a traditional midwife. The unexpected finding was that traditional midwives often perceive skilled (professional) birth attendants to be abusive of both them and the women who are transferred to hospital for emergency obstetric care. METHODS: Eighty-four traditional midwives in the Western Province of Kenya were interviewed individually or in groups with a Bukusu/Kiswahili/English-speaking interpreter. Interviews were audiotaped and the English components were transcribed verbatim. Interview transcripts and observations were thematically analysed. RESULTS: A minority of relationships between traditional midwives and skilled birth attendants were based on mutual respect and collaborative practice. However, the majority of encounters with skilled birth attendants were perceived by the traditional midwives to be abusive for them and the women requiring emergency obstetric care. In the interests of improving health outcomes for women and their newborns, interpersonal skills, including maintaining respectful communication and relationships must be a core competency for all caregivers. Providing opportunities for reciprocal learning and strategies to enhance relationships between traditional midwives and skilled birth attendants are recommended. CONCLUSION: Current global strategies to reduce maternal and newborn mortality by increasing the number of women birthing with a skilled (professional) birth attendant in an enabling environment may be limited while the reasons for traditional midwives being the caregiver of choice for the majority of women living in areas such as Western Kenya remain unaddressed.

'Too scary to think about': first time mothers' perceptions of the usefulness of antenatal breastfeeding education.

BACKGROUND: The purpose of this pilot study was to uncover the perceived usefulness of a contemporary antenatal education strategy for mother's experience of breastfeeding initiation. RESEARCH QUESTION: How useful do first time mothers perceive an antenatal education strategy to be for initiating breastfeeding? PARTICIPANTS AND METHODS: This was a simple descriptive pilot study with ten first time mothers as participants; all of whom were booked into an Australian private maternity unit for antenatal breastfeeding education, labour, birth and postpartum care. Semi-structured interviews were transcribed verbatim and thematically analysed. FINDINGS AND DISCUSSION: Antenatal education was beneficial for informing first time mothers of the practical skills required to positively initiate breastfeeding. However, this antenatal education strategy was not enough to reduce anxiety and foster the participants sense of self-confidence in their ability to breastfeed their newborns. IMPLICATIONS FOR PRACTICE: Recommendations are made to focus antenatal breastfeeding strategies on first, a strength based model that builds confidence in women's ability to successfully breastfeed. Second, in the interests of fully informed consent, women are to be advised about the physiological connection between pregnancy, labour, birth and breastfeeding and the impact that interventions such as synthetic oxytocin, caesarean section and epidural anaesthesia are likely to have on the initiation of breastfeeding.

'Mind you, there's no anaesthetist on the road': women's experiences of labouring en route.

INTRODUCTION: The aim of this article was to learn from women in rural New South Wales (NSW) Australia, their experiences of labouring en route to birth in a centralised maternity unit. METHODS: This qualitative study was exploratory and descriptive. It was part of a larger project that explored women's experiences when they birthed away from their rural communities. Participants were recruited from communities all over rural NSW where a maternity unit had closed. Forty-two female participants and three of their male partners shared their stories of 73 labours and births. This article draws on data collected during in-depth interviews with 12 participants and one partner who shared their experiences of labouring en route to a centralised maternity service. Interviews were audiotaped and transcribed verbatim for the purpose of thematic analysis. Exemplars, using the participants' own words and highlighting story are identified as a tool used for data synthesis and presentation. RESULTS: Two themes were identified. These relate to the way the risk of dangerous road travel is ignored in obstetric risk discourse, and the deprivations experienced when women labour en route. An unexpected finding was the positive nature of one woman's experience of birthing by the side of the road. CONCLUSIONS: Many participants questioned why they needed to risk unsafe road travel when their preference was to labour and birth in their local communities with a midwife.

'You can drop dead': midwives bullying women.

BACKGROUND: This paper describes how women experienced what came to be labelled as 'bullying' by a small number of midwives when they were evacuated from their rural and remote areas of NSW, Australia to a maternity unit to birth. RESEARCH QUESTION: What is the experience of women who are required to travel away from their NSW rural/remote communities to birth? PARTICIPANTS AND METHODS: Forty-two participants together with a number of their partners/support people were interviewed in depth for this qualitative, exploratory study. Upon thematic analysis of the transcribed interviews, an unexpected finding was that four participants (plus one partner) described experiences which were interpreted as bullying, by a small number of midwives working with them. Women identifying as Aboriginal were especially likely to share stories of midwifery bullying. RESULTS, DISCUSSION AND CONCLUSION: Emotional and cultural safety of women must be a prime consideration of midwives. Strategies to reverse power differentials between midwives and women are urgently required to eradicate bullying by any midwife.

The nocebo effect for women in waiting.

This paper, drawn from a larger phenomenological study, critiques the effects of "waiting" for women when they have an abnormal Pap test result. The hurt and injury incurred by women who perceive they have no choice but to become patient waiters in a health system that seemingly values the time of the health care provider over the health care recipient is discussed. These iatrogenic, unintended, harmful consequences are referred to as the nocebo effect. The participants provide the principal voices and their stories are dialogued to a lesser degree with the literature and the discourse of critical theorists who question power relationships in health professional practice. The purpose of this paper is served when the women's stories strip away some of the taken-for-granted, invisible aspects of the health professional's power.