Rural healthcare workforce preparation, response, and work during the COVID-19 pandemic in Australia: Lessons learned from in-depth interviews with rural health service leaders.

BACKGROUND: Low population density, geographic spread, limited infrastructure and higher costs are unique challenges in the delivery of healthcare in rural areas. During the COVID-19 pandemic, emergency powers adopted globally to slow the spread of transmission of the virus included population-wide lockdowns and restrictions upon movement, testing, contact tracing and vaccination programs. The aim of this research was to document the experiences of rural health service leaders as they prepared for the emergency pandemic response, and to derive from this the lessons learned for workforce preparedness to inform recommendations for future policy and emergency planning. METHODOLOGY AND METHODS: Interviews were conducted with leaders from two rural public health services in Australia, one small (500 staff) and one large (3000 staff). Data were inductively coded and analysed thematically. PARTICIPANTS: Thirty-three participants included health service leaders in executive, clinical, and administrative roles. FINDINGS: Six major themes were identified: Working towards a common goal, Delivery of care, Education and training, Organizational governance and leadership, Personal and psychological impacts, and Working with the Local Community. Findings informed the development of a applied framework. CONCLUSION: The study findings emphasise the critical importance of leadership, teamwork and community engagement in preparing the emergency pandemic response in rural areas. Informed by this research, recommendations were made to guide future rural pandemic emergency responses or health crises around the world.

Shared Decision Making in Perinatal Care.

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"I always felt like I wasn't supposed to be there". An international qualitative study of fathers' engagement in family healthcare during transition to fatherhood.

OBJECTIVE: Engagement of fathers in family health services confers benefits for the health and wellbeing of the whole family. The childbirth continuum is traditionally considered a feminine event, however, commensurate with the changing paradigm of gender equity in family healthcare worldwide, the role of fathers is in transformation. The aim of the study is to explore father's perceptions and experiences of healthcare engagement during pregnancy and early infant care. DESIGN: Qualitative free-text questions were embedded in a large multi-country, cross-sectional survey, to explored fathers' attendance, participation, and experience of health care during appointments with their pregnant partner and/or baby. SETTING AND PARTICIPANTS: Expectant and new fathers were recruited through Prolific®, an international paid online survey platform. FINDINGS: Qualitative responses (n=889) were provided by fathers from 28 countries, with experiences of a range of contexts and models of care; 46.8% of whose partners were pregnant and 53.2% had given birth since 2020. The findings suggest that although most fathers wanted to attend and participate in maternity and early parenting-related healthcare, multiple barriers were identified at the individual father, organisational context, and societal levels. Fathers reported negative social factors such as gender bias and restrictive gender norms as barriers to their healthcare engagement. In contrast, factors that enabled fathers to overcome barriers included the fathers' feelings of confidence in their partner's autonomy and decision-making skills, trusted professional relationships with clinicians, and clinicians with good interpersonal skills. KEY CONCLUSIONS: Multiple barriers restrict the participation of fathers in healthcare for childbearing and early parenting. Knowledge of these barriers can inform healthcare redesign to include more successful engagement strategies for fathers, to benefit fathers, mothers, and infants alike. IMPLICATIONS FOR PRACTICE: Health professionals consulting with the mother, father and infant triad are ideally placed to address the healthcare needs of both parents. Early engagement of fathers in family health care by use of inclusive interpersonal skills and the development of a trusted relationship has potential to improve paternal mental health, and may be associated with benefits for the health, wellbeing and safety of the whole family.

Health literacy among fathers and fathers-to-be: a multi-country, cross-sectional survey.

During pregnancy and early fatherhood, men are at higher risk of poor health, exacerbated by low engagement by healthcare services. Yet the transition to fatherhood presents an opportunity for men to improve their health and health behaviours. Health literacy refers to individuals' competence in accessing and applying health information. Poor health literacy is associated with poor health and low help-seeking. The aim of this study was to identify health literacy strengths, needs and profiles among fathers. Men who were expecting a baby ('antenatal') or had become fathers in the past 18 months ('postnatal') were recruited through an international, online paid survey platform. The survey included the nine-scale Health Literacy Questionnaire (HLQ). Of 889 survey respondents (n = 416, 46.5% antenatal; n = 473, 53.5% postnatal), 274 (31.0%) were residing in the USA and 239 (27.0%) in the UK. Relatively higher scores were reported for HLQ scales relating to having sufficient information and finding and understanding this information, as well as social support for health. Relatively lower scores were obtained for scales relating to actively managing one's own health and navigating the health care system. Three scale scores were significantly lower among nulliparous than multiparous men. Seven health literacy profiles were identified. In conclusion, while fathers have some health literacy strengths, they also experience some barriers, particularly first-time fathers. Awareness of diverse health literacy profiles among fathers may assist in developing strategies to strengthen health services' capacity to meet fathers' needs and reduce risks to their health at this critical juncture in families' lives.

Insights from using an outcomes measurement properties search filter and conducting citation searches to locate psychometric articles of tools used to measure context attributes.

OBJECTIVES: To describe our experience with using a methodological outcomes measurement search filter (precise and sensitive versions of a filter designed to locate articles that report on psychometric properties of measurement tools) and citation searches to locate psychometric articles for tools that can be used to measure context attributes. To compare the precise filter when used alone and with reference list checking to citation searching according to number of records found, precision, and sensitivity. RESULTS: Using the precise filter, we located 130 of 150 (86.6%) psychometric articles related to 22 of 31 (71.0%) tools that potentially measured an attribute of context. In a subset of six tools, the precise filter alone was more precise than searching with the precise filter combined with reference list searching, or citation searching alone. The precise filter combined with reference list checking was the most sensitive search method examined. Overall, we found the precise filter helpful for our project as it decreased record screening time. For non-patient reported outcomes tools, we had less success with locating psychometric articles using the precise filter because some psychometric articles were not indexed in PubMed. More research that systematically evaluates database searching methods is needed to validate our findings.

The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature.

PROBLEM: Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice. BACKGROUND: Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences. AIMS: To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice. FINDINGS: Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice. DISCUSSION: Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system. CONCLUSIONS: There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.

Labouring Together: Women's experiences of "Getting the care that I want and need" in maternity care.

OBJECTIVE: Poor interprofessional collaboration and lack of decision-making with women have been identified as being detrimental to the quality, safety, and experience of maternity care. The aim of the Labouring Together study was to explore childbearing women's preferences for and experiences of collaboration and control over decision-making in maternity care. DESIGN: A sequential, mixed-method, multi-site case study approach was used to explore the perceptions and experiences of childbearing women regarding collaboration and decision-making. Women's preferred role for decision-making compared to the actual experiences, and the influences upon their preferences and experiences of collaboration were explored using semi-structured interviews. An inductive approach was used for qualitative analysis of interviews, and cross-case analyses were conducted using replication logic. SETTING: Postnatal wards of 1 private and 3 public maternity services in both metropolitan and regional Victoria, Australia. PARTICIPANTS: Postnatal women, over the age of 18 years (n=182). FINDINGS: Half (48.3%) of the participants indicated a preference for a shared decision-making role and 35% preferred an active role. Only 16.7% participants indicated a preference for a passive role, however 24.4% of women reported experiencing a passive decision-making role during their maternity care. Statistically significant differences were also identified between preferences for and experiences of decision-making among women who chose the private obstetrician model of maternity care compared to the public maternity care system. Negative impacts upon women's autonomy over decision-making included: poor access to midwifery models of care; poor access to relational continuity of care; poor understanding of the rights of the woman; inadequate information for women about the risks and benefits of all proposed interventions; and a bureaucratic style of decision-making based upon a dominant discourse of risk avoidance that could ultimately veto the woman's choice. KEY CONCLUSIONS: Despite evidence of the benefits for women of having autonomy over decision-making in their own care, fundamental barriers were identified that hindered women's participation in collaboration in maternity care. Shared decision-making with childbearing women is not routine practice in maternity care in Victoria, Australia. IMPLICATIONS FOR PRACTICE: Relational continuity of care is imperative to promote the autonomy of childbearing women and an environment conducive to women's active engagement in maternity care and participation in shared decision-making.

Midwives' experiences of father participation in maternity care at a large metropolitan health service in Australia.

OBJECTIVE: Engagement of fathers to participate in pregnancy, birth and early postnatal care has significant advantages for women and infants as well as fathers. In Australia, guidelines for midwifery practice do not include specific recommendations about father-inclusive care, and models for publicly funded maternity care do not extend to the provision of care tailored specifically towards the needs of fathers. This study investigated the perceptions of midwives regarding their role in fathers' wellbeing, the extent of fathers' attendance at and participation in their services, advantages and disadvantages of father participation and barriers and enablers to father engagement. DESIGN: Convergent mixed methods, cross-sectional. SETTING: A large metropolitan public maternity hospital that provides care to some of the most socio-economically disadvantaged suburbs and multi-cultural communities in Melbourne, Australia. PARTICIPANTS: All midwives employed at the hospital (n=196) were invited to participate. METHODS: Anonymous online survey and semi-structured interviews. Descriptive statistics were calculated for quantitative survey responses. Interview data and qualitative survey responses were analysed thematically. FINDINGS: Forty midwives working in all areas of maternity services across the hospital completed surveys, and six participated in interviews. The data illustrate the dilemma faced by midwives in their specific role of supporting women and babies. On the one hand, participants indicated that fathers' wellbeing should be part of their role and named many advantages of father participation in maternity services, including support and advocacy for mothers and bonding with infants. Participants estimated that most fathers attend births and visit their partner and infant on the postnatal ward, 52% attend antenatal appointments and 76% are present at postnatal home visits. Participants reported several midwife strategies and health service factors which facilitate father attendance and active engagement. On the other hand, participants reported several barriers to father engagement, including antenatal appointment schedules which are at odds with fathers' work commitments and the lack of on-site group antenatal education. Some of the barriers they reported are specific to the vulnerable communities for which they provide maternity care. Extraordinary circumstances were reported, including fathers working overseas, fathers in prison, new immigrant status that is often accompanied by a lack of family support to care for other children even during labour and birth, and poor socio-economic status. In addition, in many cultures, pregnancy and birth are seen as "women's work"; fathers would not traditionally be involved. Participants also reported that midwives lack training and confidence in engaging fathers, particularly in responding to fathers with mental health concerns. When providing care for families at risk of family violence, father attendance was perceived a significant disadvantage. KEY CONCLUSIONS: Midwife-provided health services represent a significant opportunity to include and address fathers, and midwives recognise the significant advantages of engaging fathers, unless there is a risk of family violence. However, midwives currently report lack of training and confidence in addressing fathers' needs, and several individual, social, cultural, and health service factors can present barriers to engaging fathers. IMPLICATIONS FOR PRACTICE: Given the substantial benefits of engaging fathers for women and infants, we argue that maternity services should promote father engagement, for example by offering after hours appointment schedules, free antenatal and parenting education, and workshops to upskill midwifery staff. Education regarding the importance of father participation and skills for working with fathers should be included in the undergraduate preparation of midwives and other key maternity care professionals. Addressing the challenges of providing care to a multicultural community requires sensitive discussion with families from each of those cultures.

The association between ragged or incomplete membranes and postpartum haemorrhage: A retrospective cohort study.

BACKGROUND: The association between an incomplete placenta and postpartum haemorrhage (PPH) is well documented; however, the significance of ragged or incomplete membranes has not been explored as an independent risk factor for PPH. AIMS: To explore the association between the completeness of the amniotic and chorionic membranes and the risk of PPH, independent to placental status. MATERIALS AND METHODS: 37 176 birth records were retrospectively extracted from the period 1 July, 2008 to 30 June, 2016 from the databases of two public hospitals in Melbourne, Australia. Following application of specific exclusion and inclusion criteria, including non-complete placentas, 5718 records were available for analysis. These records were grouped based on membrane status (complete, ragged or incomplete) and outcome (PPH or no PPH). RESULTS: Primary PPH rates were 14.8% in women with complete membranes, 20.2% in women with ragged membranes and 25.8% in women with incomplete membranes. Following statistical adjustment, the risk ratios for PPH were 1.32 (95% CI: 1.15-1.50) and 1.70 (95% CI: 1.41-2.04) in women with ragged and incomplete membranes, respectively. CONCLUSIONS: Both ragged and incomplete membranes were found to be independent risk factors for primary PPH. This previously un-discussed association has the potential to influence clinical practice changes, particularly with regard to the ongoing clinical relevance and use of the terms 'ragged' and 'incomplete' membranes.

Labouring Together: collaborative alliances in maternity care in Victoria, Australia-protocol of a mixed-methods study.

INTRODUCTION: For over a decade, enquiries into adverse perinatal outcomes have led to reports that poor collaboration has been detrimental to the safety and experience of maternity care. Despite efforts to improve collaboration, investigations into maternity care at Morecambe Bay (UK) and Djerriwarrh Health Services (Australia) have revealed that poor collaboration and decision-making remain a threat to perinatal safety. The Labouring Together study will investigate how elements hypothesised to influence the effectiveness of collaboration are reflected in perceptions and experiences of clinicians and childbearing women in Victoria, Australia. The study will explore conditions that assist clinicians and women to work collaboratively to support positive maternity outcomes. Results of the study will provide a platform for consumers, clinician groups, organisations and policymakers to work together to improve the quality, safety and experience of maternity care. METHODS AND ANALYSIS: 4 case study sites have been selected to represent a range of models of maternity care in metropolitan and regional Victoria, Australia. A mixed-methods approach including cross-sectional surveys and interviews will be used in each case study site, involving both clinicians and consumers. Quantitative data analysis will include descriptive statistics, 2-way multivariate analysis of variance for the dependent and independent variables, and χ2 analysis to identify the degree of congruence between consumer preferences and experiences. Interview data will be analysed for emerging themes and concepts. Data will then be analysed for convergent lines of enquiry supported by triangulation of data to draw conclusions. ETHICS AND DISSEMINATION: Organisational ethics approval has been received from the case study sites and Deakin University Human Research Ethics Committee (2014-238). Dissemination of the results of the Labouring Together study will be via peer-reviewed publications and conference presentations, and in written reports for each case study site to support organisational change.