Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study.

BACKGROUND: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). METHODS: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. RESULTS: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. CONCLUSIONS: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

Development of a co-designed, evidence-based, multi-pronged strategy to support normal birth.

Australia's caesarean section (CS) rate has been steadily increasing for decades. In response to this, we co-designed an evidence-based, multi-pronged strategy to increase the normal birth rate in Queensland and reduce the need for CS. We conducted three workshops with a multi-stakeholder group to identify a broad range of options to reduce CS, prioritise these options, and achieve consensus on a final strategy. The strategy comprised of: universal access to midwifery continuity-of-care and choice of place of birth; multi-disciplinary normal birth education; resources to facilitate informed decision-making; respectful maternity care and positive workplace culture; and establishment of a Normal Birth Collaborative.

Nonpharmacological interventions to improve the psychological well-being of women accessing abortion services and their satisfaction with care: A systematic review.

How women perceive and experience abortion impacts their subsequent psychological well-being. This systematic review evaluated nonpharmacological interventions designed to support women undergoing abortion services and improve their psychological well-being and satisfaction with care. Searches were conducted in MEDLINE, CINAHL, the Cochrane Library, PsycINFO, Sociological Abstracts, Social Services Abstracts, and PTSD Pubs. All searches were limited to peer-reviewed articles published in English from January 2010 to February 2020. Two reviewers independently assessed study eligibility. Ten studies were included, involving four types of interventions: music therapy; social support; information support; and mandated waiting and counseling requirements on abortion access. Outcome measures were divided into four categories comprised of cognitive domains, emotional and psychological well-being, clinical symptoms, and satisfaction with care. However, there is limited evidence on intervention effects. Most studies report null or mixed intervention effects. Even though some positive effects on women's cognitive outcomes and satisfaction with care were seen, findings across studies were inconclusive. Findings also show that methodological limitations such as lack of theoretical basis, inadequate reporting and no power sample size calculation were apparent across studies. There is limited evidence about nonpharmacological interventions designed to improve women's satisfaction with abortion services or psychological outcomes subsequent to accessing abortion services. Well-designed interventions that meet the needs of service-users should be developed and rigorously tested.

The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk.

BACKGROUND: The measurement and interpretation of patient experience is a distinct dimension of health care quality. The Midwives @ New Group practice Options (M@NGO) randomized control trial of caseload midwifery compared with standard care among women regardless of risk reported both clinical and cost benefits. This study reports participants' perceptions of the quality of antenatal care within caseload midwifery, compared with standard care for women of any risk within that trial. METHODS: A trial conducted at two Australian tertiary hospitals randomly assigned participants (1:1) to caseload midwifery or standard care regardless of risk. Women were sent an 89-question survey at 6 weeks postpartum that included 12 questions relating to pregnancy care. Ten survey questions (including 7-point Likert scales) were analyzed by intention to treat and illustrated by participant quotes from two free-text open-response items. RESULTS: From the 1748 women recruited to the trial, 58% (n = 1017) completed the 6-week survey. Of those allocated to caseload midwifery, 66% (n = 573) responded, compared with 51% (n = 444) of those allocated to standard care. The survey found women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure. Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87-3.39]), quality care (2.94 [2.28-3.79]), and feeling actively involved in decision-making (3.21 [2.35-4.37]). CONCLUSIONS: Results from the study show that in addition to the benefits to clinical care and cost demonstrated in the M@NGO trial, caseload midwifery outperforms standard care in perceived quality of pregnancy care regardless of risk.

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial.

BACKGROUND: Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS: In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS: Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION: Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING: National Health and Medical Research Council (Australia).

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives.

PROBLEM: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BACKGROUND: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AIM: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. METHODS: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. FINDINGS: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001). DISCUSSION: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. CONCLUSION: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

The financial impact of offering publicly funded homebirths: A population-based microsimulation in Queensland, Australia.

BACKGROUND: Despite strong evidence of benefits and increasing consumer demand for homebirth, Australia has failed to effectively upscale it. To promote the adoption and expansion of homebirth in the public health care system, policymakers require quantifiable results to evaluate its economic value. To date, there has been limited evaluation of the financial impact of birth settings for women at low risk of pregnancy complications. OBJECTIVE: This study aimed to examine the difference in inpatient costs around birth between offering homebirth in the public maternity system versus not offering public homebirth to selected women who meet low-risk pregnancy criteria. METHODS: We used a whole-of-population linked administrative dataset containing all women who gave birth in Queensland (one Australian State) between 01/07/2012 and 30/06/2018 where publicly funded homebirth is not currently offered. We created a static microsimulation model to compare the inpatient cost difference for mother and baby around birth based on the women who gave birth between 01/07/2017 and 30/06/2018 (n = 36,314). The model comprised of a base model - representing standard public hospital care, and a counterfactual model - representing a hypothetical scenario where 5 % of women who gave birth in public hospitals planned to give birth at home prior to the onset of labour (n = 1816). Costs were reported in 2021/22 AUD. RESULTS: In our hypothetical scenario, after considering the effect of assumptive place and mode of birth for these planned homebirths, the estimated State-level inpatient cost saving around birth (summed for mother and babies) per pregnancy were: AU$303.13 (to Queensland public hospitals) and AU$186.94 (to Queensland public hospital funders). This calculates to a total cost saving per annum of AU$11 million (to Queensland public hospitals) and AU$6.8 million (to Queensland public hospital funders). CONCLUSION: A considerable amount of inpatient health care costs around birth could be saved if 5 % of women booked at their local public hospitals, planned to give birth at home through a public-funded homebirth program. This finding supports the establishment and expansion of the homebirth option in the public health care system.

A cost analysis of upscaling access to continuity of midwifery carer: Population-based microsimulation in Queensland, Australia.

OBJECTIVE: To quantify the economic impact of upscaling access to continuity of midwifery carer, compared with current standard maternity care, from the perspective of the public health care system. METHODS: We created a static microsimulation model based on a whole-of-population linked administrative data set containing all public hospital births in one Australian state (Queensland) between July 2017 to June 2018 (n = 37,701). This model was weighted to represent projected State-level births between July 2023 and June 2031. Woman and infant health service costs (inpatient, outpatient and emergency department) during pregnancy and birth were summed. The base model represented current standard maternity care and a counterfactual model represented two hypothetical scenarios where 50 % or 65 % of women giving birth would access continuity of midwifery carer. Costs were reported in 2021/22 AUD. RESULTS: The estimated cost savings to Queensland public hospital funders per pregnancy were $336 in 2023/24 and $546 with 50 % access. With 65 % access, the cost savings were estimated to be $534 per pregnancy in 2023/24 and $839 in 2030/31. A total State-level annual cost saving of $12 million in 2023/24 and $19 million in 2030/31 was estimated with 50 % access. With 65 % access, total State-level annual cost savings were estimated to be $19 million in 2023/24 and $30 million in 2030/31. CONCLUSION: Enabling most childbearing women in Australia to access continuity of midwifery carer would realise significant cost savings for the public health care system by reducing the rate of operative birth.

Enabling the context for Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services: Participatory action research.

PROBLEM: Establishment of Birthing on Country services owned and governed by Aboriginal and Torres Strait Islander Community Controlled Health Services has been slow. BACKGROUND: Birthing on Country services have demonstrated health and cost benefits and require redesign of maternity care. During the Building On Our Strengths feasibility study, use of endorsed midwives and licensing of birth centres has proven difficult. QUESTION: What prevents Community Controlled Health Services from implementing Birthing on Country services in Queensland and New South Wales? METHODS: Participatory action research identified implementation barriers. We conducted iterative document analysis of instruments to inform government lobbying through synthesis of policy, economic, social, technological, legal, and environmental factors. FINDINGS: Through cycles of participatory action research, we analysed 17 documents: 1) policy barriers prevent Community Controlled Health Services from employing endorsed midwives to provide intrapartum care in public hospitals; 2) economic barriers include lack of sustainable funding stream and inadequate Medicare-billing for endorsed midwives; and 3) legal barriers require a medical practitioner in a birth centre. While social barriers (e.g., colonisation, medicalisation) underpin regulations, these were beyond the scope; technological and environmental barriers were not identified. DISCUSSION: Findings are consistent with the literature on barriers to midwifery practice. Recommendations include a national audit of barriers to Birthing on Country services including healthcare practice insurance, and development of a funding stream. Additionally, private maternity facility regulation must align with evidence on safe birth centre operation. CONCLUSION: Government can address barriers to scale-up of Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services.

Is a randomised controlled trial of a maternity care intervention for pregnant adolescents possible? An Australian feasibility study.

BACKGROUND: The way in which maternity care is provided affects perinatal outcomes for pregnant adolescents; including the likelihood of preterm birth. The study purpose was to assess the feasibility of recruiting pregnant adolescents into a randomised controlled trial, in order to inform the design of an adequately powered trial which could test the effect of caseload midwifery on preterm birth for pregnant adolescents. METHODS: We recruited pregnant adolescents into a feasibility study of a prospective, un-blinded, two-arm, randomised controlled trial of caseload midwifery compared to standard care. We recorded and analysed recruitment data in order to provide estimates to be used in the design of a larger study. RESULTS: The proportion of women aged 15-17 years who were eligible for the study was 34% (n=10), however the proportion who agreed to be randomised was only 11% (n = 1). Barriers to recruitment were restrictive eligibility criteria, unwillingness of hospital staff to assist with recruitment, and unwillingness of pregnant adolescents to have their choice of maternity carer removed through randomisation. CONCLUSIONS: A randomised controlled trial of caseload midwifery care for pregnant adolescents would not be feasible in this setting without modifications to the research protocol. The recruitment plan should maximise opportunities for participation by increasing the upper age limit and enabling women to be recruited at a later gestation. Strategies to engage the support of hospital-employed staff are essential and would require substantial, and ongoing, work. A Zelen method of post-randomisation consent, monetary incentives and 'peer recruiters' could also be considered.

Health engagement: a systematic review of tools modifiable for use with vulnerable pregnant women.

OBJECTIVE: To examine available health engagement tools suitable to, or modifiable for, vulnerable pregnant populations. DESIGN: Systematic review. ELIGIBILITY CRITERIA: Original studies of tool development and validation related to health engagement, with abstract available in English, published between 2000 and 2022, sampling people receiving outpatient healthcare including pregnant women. DATA SOURCES: CINAHL Complete, Medline, EMBASE and PubMed were searched in April 2022. RISK OF BIAS: Study quality was independently assessed by two reviewers using an adapted COSMIN risk of bias quality appraisal checklist. Tools were also mapped against the Synergistic Health Engagement model, which centres on women's buy-in to maternity care. INCLUDED STUDIES: Nineteen studies were included from Canada, Germany, Italy, the Netherlands, Sweden, the UK and the USA. Four tools were used with pregnant populations, two tools with vulnerable non-pregnant populations, six tools measured patient-provider relationship, four measured patient activation, and three tools measured both relationship and activation. RESULTS: Tools that measured engagement in maternity care assessed some of the following constructs: communication or information sharing, woman-centred care, health guidance, shared decision-making, sufficient time, availability, provider attributes, discriminatory or respectful care. None of the maternity engagement tools assessed the key construct of buy-in. While non-maternity health engagement tools measured some elements of buy-in (self-care, feeling hopeful about treatment), other elements (disclosing risks to healthcare providers and acting on health advice), which are significant for vulnerable populations, were rarely measured. CONCLUSIONS AND IMPLICATIONS: Health engagement is hypothesised as the mechanism by which midwifery-led care reduces the risk of perinatal morbidity for vulnerable women. To test this hypothesis, a new assessment tool is required that addresses all the relevant constructs of the Synergistic Health Engagement model, developed for and psychometrically assessed in the target group. PROSPERO REGISTRATION NUMBER: CRD42020214102.

Impact of the Thompson method on breastfeeding exclusivity and duration: Multi-method design.

BACKGROUND: How hospital clinicians facilitate breastfeeding in the first 48-72 h is critical to breastfeeding exclusivity and duration. Mothers who discharge hospital directly breastfeeding are more likely to continue exclusively breastfeeding at 3-months. OBJECTIVE: To assess the impact of facility-wide implementation of a physiological breastfeeding method (the Thompson method) on direct breastfeeding at hospital discharge and exclusive breastfeeding at 3-months of age. DESIGN: Multi-method design using interrupted time series analysis and surveys. SETTING(S): An Australian tertiary maternity hospital. PARTICIPANTS: 13,667 mother-baby pairs (interrupted time series analysis) and 495 postnatal mothers (surveys). METHODS: The Thompson method includes cradle position and hold, alignment of mouth-to-nipple, baby-led connection and seal, maternal fine-tuning for symmetry, and leisurely duration. We used a large pre-post implementation dataset and conducted interrupted time series analysis using a 24-month baseline period (January 2016 - December 2017); and a 15-month post-implementation period (April 2018 - June 2019). We recruited a sub-sample of women to complete surveys at hospital discharge and 3-months postpartum. Surveys were primarily used to measure impact of Thompson method on exclusive breastfeeding at 3-months, compared with a baseline survey conducted in same setting. RESULTS: Following implementation of the Thompson method, the declining trend in direct breastfeeding at hospital discharge was significantly averted by 0.39% each month relative to baseline (95% CI: 0.03% to 0.76%; p = 0.037). While the 3-month exclusive breastfeeding rate in the Thompson group was 3 percentage points higher than the baseline group; this result did not reach statistical significance. However, a subgroup analysis of women who discharged hospital exclusively breastfeeding revealed the relative odds of exclusive breastfeeding at 3-months in the Thompson group was 0.25 (95% CI: 0.17 to 0.38; p < 0.001), significantly better than the baseline group (Z = 3.23, p < 0.01) where the relative odds was only 0.07 (95% CI: 0.03 to 0.19; p < 0.001). CONCLUSIONS: Implementation of the Thompson method for well mother-baby pairs improved direct breastfeeding trends at hospital discharge. For women who discharged hospital exclusively breastfeeding, exposure to the Thompson method reduced the risk of exclusive breastfeeding discontinuation by 3-months. The positive impact of the method was potentially confounded by partial implementation and a parallel rise in birth interventions which undermine breastfeeding. We recommend strategies to strengthen clinician buy-in to the method, and future research using a cluster randomised trial design. TWEETABLE ABSTRACT: Facility-wide implementation of the Thompson method improves direct breastfeeding at hospital discharge and predicts breastfeeding exclusivity at 3-months.

Effects of the STress-And-coping suppoRT (START) intervention on depression and coping of Chinese women seeking a first-trimester abortion: A randomized controlled trial.

BACKGROUND: Abortion is a stressful life event associated with wide variability in women's perceptions and adjustment. There is scarce evidence on interventions to help women cope with abortion and achieve positive psychological health outcomes. This study tested the effect of a stress and coping theory-formed intervention (START) on depression and coping of Chinese women undergoing a first-trimester abortion. METHODS: A randomized controlled trial was conducted at a Chinese metropolitan hospital. 110 participants were recruited and randomized to intervention group (START + standard care) or control group (standard care) with a 1:1 allocation ratio. The primary outcome was depression at two-week post-abortion. Surveys were completed by participants when they sought abortion services (baseline), two and six-week post-abortion. RESULTS: At two-week post-abortion, women allocated to the intervention group compared to the control group, had significantly lower depression scores (aOR -2.81 [-4.12 to -1.50]), higher problem-focused coping (aOR 1.64 [0.36-2.93]), lower dysfunctional coping (aOR -2.29 [-3.69 to -0.89]), higher self-efficacy (aOR 3.17 [-0.42-5.94]), and higher personal growth scores (aOR 4.41 [0.30-8.53]). Lower depression scores at two-weeks were mediated by lower dysfunctional coping (mediated effect 0.96 [0.25, 1.74]; proportion of overall effect 36 % [9 %, 65 %]). CONCLUSION: Chinese women allocated to receive START had lower depression and better coping at two-week post-abortion. This brief, online intervention contributed to women's self-efficacy and positive perceptions of social support, abortion experience, and personal growth. Maintenance of the effects need further research.

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis.

BACKGROUND: A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one - warm perineal compresses - has highest level evidence. There is scant published research about the impact of implementation of perineal bundles. QUESTION: How does a perineal care bundle impact midwifery practice in Australian maternity hospitals? METHODS: Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power. FINDINGS: We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission. DISCUSSION: The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants' responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences. CONCLUSION: The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy - women's and their own - by using clinical judgement, evidence, and woman-centred care.

The STress-And-Coping suppoRT Intervention (START) for Chinese Women Undergoing Abortion: A Randomized Controlled Trial Protocol.

BACKGROUND: Although undergoing an abortion is stressful for most women, little attention has been given to their psychological wellbeing. This protocol aims to assess the feasibility, acceptability, and primary effects of a complex intervention to promote positive coping behaviors and alleviate depression symptoms among Chinese women who have undergone an abortion. METHODS: A two-arm randomized controlled trial design will be used. Participants will be recruited at their first appointment with the abortion clinic and randomly allocated to receive either the Stress-And-Coping suppoRT (START) intervention (in addition to standard abortion care) or standard care only. All participants will be followed-up at two- and six-weeks post-abortion. Approval has been granted by local and university ethics committees. This research was supported by an Australian Government Research Training Program Scholarship. DISCUSSION: The results will assist refinement and further evaluations of the START intervention, contribute to improved abortion care practices in China, and enrich the evidence on improving women's psychological well-being following abortion in China. TRIAL REGISTRATION: Registered at the Chinese Clinical Trials.gov: ChiCTR2100046101. Date of registration: 4 May 2021.

Evaluation of a First Peoples-led, emotion-based pedagogical intervention to promote cultural safety in undergraduate non-Indigenous health professional students.

BACKGROUND: Undergraduate health students learn cultural safety in complex and emotional ways. Pedagogies that account for these complexities must be developed and evaluated. OBJECTIVES: To evaluate a First Peoples-led emotion-based pedagogical intervention on non-Indigenous health professional students' development towards cultural safety. DESIGN: A pre-post mixed-methods intervention design. SETTING AND PARTICIPANTS: All undergraduate health students undertaking a semester-long First Peoples cultural safety course (n = 395) were invited to participate. METHODS: The intervention involved students' written reflections and comfort (1 = very uncomfortable to 5 = very comfortable) with workshop content, using a gawugaa-gii-mara (head, heart, hands) form. The educator analysed student responses collected on the form, to prompt discussion in a series of four workshops. Students also completed the online 20-item Student Emotional Learning in Cultural Safety Education Instrument (SELCSI) which has two scales, Witnessing and Comfort. gawugaa-gii-mara responses were thematically coded. Paired sample t-tests examined differences over time. Eta squared determined effect size. RESULTS: There were 102 matched pre-post-intervention surveys. Both SELCSI scales had excellent internal consistency (Witnessing α = 0.80, Comfort α = 0.92). A statistically significant difference was observed between students' mean scores on the Witnessing scale prior to the course (M = 47.10, SD = 6.51) compared to post-course (53.04, SD = 4.80), t(95) = 8.70, p < 0.001 (two-tailed) with a large effect size (d = 0.88). Most Comfort scale items increased but were not statistically significant. Data from the gawugaa-gii-mara intervention (n = 162 written responses) revealed students were challenged by self-reflexivity. There was a disconnect between what students had learnt (gawugaa), what they had felt (gii) and how this would be applied in professional practice (mara). CONCLUSIONS: The First Peoples-led, emotions-based pedagogical intervention was brief, meaningful and effective. As students grappled with their emotional connection to self-reflexivity as well as their ability to translate new knowledge into culturally safe practice, these offer important avenues for future research.

Designing a Needs-Oriented Psychological Intervention for Chinese Women Undergoing an Abortion.

Accessing good quality abortion care is a fundamental human right and contributes to achieving Sustainable Development Goals. However, well-designed abortion care that meets women's needs is limited. This study aims to systematically develop an intervention to promote the psychological well-being of Chinese women undergoing an abortion. A five-step iterative approach informed by intervention mapping was undertaken to determine the intervention design. Step 1 used in-depth interviews with 14 Chinese women undergoing an abortion to assess real-life stressors and support needs. We identified eight stressors and found women's support needs varied with the time trajectory of the abortion. Step 2 used a focus group discussion with care providers to select modifiable stressors that impact negative psychological outcomes. In Step 3 and Step 4, we determined and integrated the exact strategies to eliminate or mitigate possible modifiable stressors by incorporating information from in-depth interviews and the Transactional Model of Stress and Coping. The integrated strategies were instructional support, informational support, and timely communication. In Step 5, we composed the detailed intervention design according to the best available evidence and, to confirm content validity, consulted 10 women who had undergone abortion in the previous 2-6 weeks. The intervention was titled STress-And-coping suppoRT (START), which included four interacting components: (1) a face-to-face consultation at the first appointment; (2) a printed booklet with information on abortion, self-care, and managing emotions and intimate relationships; (3) a WeChat-based online public profile page offering the same information as the booklet; (4) a telephone hotline. This study paves the way for a new approach to addressing the psychological needs of women experiencing abortion in China. The rigorous process provides an example of developing tailored health promotion interventions.

Navigating pregnancy and early motherhood in prison: a thematic analysis of mothers' experiences.

BACKGROUND: Maternal imprisonment negatively impacts mothers and their children and is likely to have lifelong and intergenerational sequelae. In many jurisdictions nationally and internationally, young children (usually those less than 5 years) can reside with their mothers in prison. However, there is considerable debate regarding the impact of prison environments on incarcerated mothers and their children who are born, and/or raised in prison. Research to date on the pregnancy and mothering experiences of imprisoned mothers and their preferences for care arrangements for their babies and young children is limited. METHODS: This study was part of the Transforming Corrections to Transform Lives project, in which workshops were conducted with imprisoned mothers to understand their needs while in custody and post-release, and the kind of supports and system changes that are required to meet those needs. Incarcerated mothers (n = 75) participated in seven workshops conducted across four Queensland prisons. Themes were generated through reflexive thematic analysis. RESULTS: Three themes characterised mothers' experiences of being pregnant and undertaking a mothering role of a young child while in prison. First, for most mothers, imprisonment adds vulnerability and isolation during pregnancy and childbirth. Second, although mothers felt that residing together with their children in prison motivated them to change for a better future, they were concerned about the potential negative impact of the prison environment on the child's development. Lastly, most mothers voiced losing autonomy and agency to practice motherhood independently within custodial settings. Mothers expressed a need for the correctional system to be adapted, so it is better equipped to address the unique and additional needs of mothers with young children. CONCLUSION: Mothers' experiences indicated that the correctional system and policies, which were predominantly designed for men, do not adequately address the varied and complex needs of pregnant women, mothers, and their young children. Imprisonment of pregnant women and mothers with young children should be the last resort, and they should be provided with holistic, individually tailored support, most preferably in community settings, to address their multiple intersecting needs.

A randomised controlled trial of caseload midwifery care: M@NGO (Midwives @ New Group practice Options).

BACKGROUND: Australia has an enviable record of safety for women in childbirth. There is nevertheless growing concern at the increasing level of intervention and consequent morbidity amongst childbearing women. Not only do interventions impact on the cost of services, they carry with them the potential for serious morbidities for mother and infant.Models of midwifery have proliferated in an attempt to offer women less fragmented hospital care. One of these models that is gaining widespread consumer, disciplinary and political support is caseload midwifery care. Caseload midwives manage the care of approximately 35-40 a year within a small Midwifery Group Practice (usually 4-6 midwives who plan their on call and leave within the Group Practice.) We propose to compare the outcomes and costs of caseload midwifery care compared to standard or routine hospital care through a randomised controlled trial. METHODS/DESIGN: A two-arm RCT design will be used. Women will be recruited from tertiary women's hospitals in Sydney and Brisbane, Australia. Women allocated to the caseload intervention will receive care from a named caseload midwife within a Midwifery Group Practice. Control women will be allocated to standard or routine hospital care. Women allocated to standard care will receive their care from hospital rostered midwives, public hospital obstetric care and community based general medical practitioner care. All midwives will collaborate with obstetricians and other health professionals as necessary according to the woman's needs. DISCUSSION: Data will be collected at recruitment, 36 weeks antenatally, six weeks and six months postpartum by web based or postal survey. With 750 women or more in each of the intervention and control arms the study is powered (based on 80% power; alpha 0.05) to detect a difference in caesarean section rates of 29.4 to 22.9%; instrumental birth rates from 11.0% to 6.8%; and rates of admission to neonatal intensive care of all neonates from 9.9% to 5.8% (requires 721 in each arm). The study is not powered to detect infant or maternal mortality, however all deaths will be reported. Other significant findings will be reported, including a comprehensive process and economic evaluation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000349246.