Mothers' experiences of pain during breastfeeding in the early postnatal period: A short report in a Swedish context.

OBJECTIVES: The objective was to investigate the prevalence of mothers who experienced pain during breastfeeding in the early postnatal period and to describe associated factors. METHODS: Medical records of 987 mothers and their babies were scrutinized. Chi-square Test, McNemar's test, and relative risk with a 95% confidence interval were applied for analysis. RESULTS: During the in-hospital postnatal stay, 19.5% mothers experienced pain during breastfeeding. At discharge, the rate was 8.8% (ρ < .001) and at the follow-up hospital visit 2 to 3 days after birth 17.5% (ρ = .104). Pain when breastfeeding was associated with primiparity (RR 2.02; 95% CI 1.53-2.66), epidural block during labor (RR 1.50; 95% CI 1.17-1.94), cracked nipples (RR 5.94; 95% CI 4.84-7.27), the use of a nipple shield (RR 6.34; 95% CI 5.43-7.41), supplementary feeding (RR 2.19; 95% CI 1.71-2.80), and longer hospital stay (RR 1.88; 95% CI 1.46-2.42). CONCLUSIONS: During the early postnatal period, Swedish mothers commonly experienced pain during breastfeeding. Although the rate dropped at discharge, it rose again by the time mothers returned for their follow-up visit. The rebound rate could be explained by breast engorgement, a baby's shallow latch or the effect of an epidural block. Midwives and nurses assisting women during intrapartum and postpartum care must be aware of factors associated with pain during early breastfeeding.

Perinatal incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and Wexner Scale.

AIM: The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the Wexner Scale have been included in the International Consortium for Health Outcomes Measurement core outcome set during pregnancy and childbirth, to measure urinary and anal incontinence. The reliability and validity of these instruments have not been fully evaluated in maternity populations. The aim of this study was to conduct a psychometric evaluation of the ICIQ-UI SF and Wexner Scale. METHODS: Consecutive pregnant women (n = 309) who booked for care at one Australian birth facility between August 2017 and April 2018 completed the online surveys. Women who screened positive for urinary and/or anal incontinence were administered the ICIQ-UI SF and/or Wexner Scale during pregnancy ( <27 and 36-weeks) and postpartum (6 and 26-weeks). Scale internal consistency, construct validity, and responsiveness were evaluated. FINDINGS: In women with urinary incontinence, the ICIQ-UI SF demonstrated good internal consistency during pregnancy (baseline and 36 weeks) and 6-weeks postpartum (mean inter-item correlation: 0.47, 0.39, and 0.46, respectively), recorded significant change across three time-points, and was sensitive to group differences in age and obesity during pregnancy. Wexner Scale was unsuitable for psychometric analysis due to insufficient numbers of women with anal incontinence. CONCLUSION: The ICIQ-UI SF is a valid and reliable instrument to measure urinary incontinence during pregnancy and postpartum. The findings support the inclusion of the ICIQ-UI SF in the International Consortium for Health Outcomes Measurement core outcome set for use during the perinatal period. Psychometric analysis of the Wexner Scale in larger maternity populations is recommended.

Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population - validation of the PROMIS Global Short Form.

BACKGROUND: Health related quality of life is a critical concept during the perinatal period but remains under-researched. The International Consortium for Health Outcomes Measurement have included the Patient Reported Outcomes Measurement Information System (PROMIS®) Global Short Form (GSF) in their core outcome set for pregnancy and childbirth to measure health related quality of life. The PROMIS GSF has not been fully evaluated as a valid and reliable instrument in this population. This study assessed the psychometric properties of the PROMIS GSF during pregnancy and postpartum period. METHODS: PROMIS GSF was administered to a sample of 309 pregnant women at four time-points during pregnancy (≤ 27 and 36-weeks) and postpartum (6- and 26-weeks). The structural validity, internal consistency reliability, construct validity, and responsiveness of the PROMIS GSF were evaluated. The internal structure of the PROMIS GSF was explored using Rasch Measurement Theory. Response format, item fit, differential item functioning (item bias), dimensionality of the scale and its targeting were assessed. RESULTS: Two revised subscales (Mental Health: four items; and Physical Health: five items) showed good fit to the Rasch model. The revised mental health subscale demonstrated good internal consistency reliability during pregnancy and postpartum period (α = .88 and .87, respectively). The internal consistency reliability of the physical health subscale was adequate (α = .76 and .75, respectively). The revised mental health subscale was sensitive to group differences according to a history of mental health disorder, income, smoking status, drug use, stress levels and planned versus unplanned pregnancy. Differences in scores on the revised physical subscale were detected for groups based on obesity, income, drug use, smoking status, stress, and history of mental health disorders. Scores on both subscales recorded significant changes across the four time-points, spanning pregnancy and postpartum period. CONCLUSIONS: The revised version of the PROMIS GSF was better able to measure mental and physical health during pregnancy and postpartum period compared to the original version. Findings support the clinical and research application of the PROMIS GSF within the International Consortium for Health Outcomes Measurement Standard Set of Outcome Measures for Pregnancy and Childbirth. Ongoing psychometric analysis of the PROMIS GSF is recommended in other maternity populations.

Empathy in pregnant women and new mothers: a systematic literature review.

OBJECTIVE: This systematic review explores changes in perinatal empathy and influence on maternal behaviours and child development. BACKGROUND: The well-being and development of infants are commonly linked to their mothers' capacity for empathy. However, characteristic changes during pregnancy and childbirth including sleep deprivation, mood and cognitive difficulties may disrupt empathic processing. METHODS: Original research papers (n = 7413) published in English language peer-reviewed academic journals were obtained by searching four electronic databases PsycINFO, PubMed, Scopus and CINAHL. Inclusion criteria were studies reporting empathy of women in the period from pregnancy to 12 months postpartum. Empathy was operationalised as a general tendency of empathic emotional responding and cognitive perspective taking. Thirteen studies were systematically assessed using the Critical Appraisal Skills Programme criteria. RESULTS: Impaired empathy in mothers, due most notably to high personal distress, was associated with risk of neglect or maltreatment of children and was partially explained by mothers' aversive response to infant crying. CONCLUSION: Few studies present empathy as a central theme. There is a paucity of definitional parameters and theoretical linkages and over-reliance on brief self-report indices of empathy. Future studies need to be theory based, incorporate experimental approaches, and provide greater sampling diversity toadvance our understanding of empathy in perinatal women.

Personal, professional and workplace factors that contribute to burnout in Australian midwives.

AIM: This study aimed to identify personal, professional and workplace factors that contribute to burnout in midwives. BACKGROUND: Burnout is prevalent in the midwifery workforce. Burnout adversely affects the well-being of midwives, diminishes the quality of care they provide and can shorten career duration. DESIGN: Self-administered online survey. The survey included the Copenhagen Burnout Inventory and personal and professional variables related to age, children, years of experience, role, model of care and satisfaction with work life. Midwives were invited to participate via an email sent from the Australian College of Midwives and through professional networks between June and July 2014. Variables associated with burnout were entered in a multinomial logistic regression. RESULTS: A total of 1,037 responses were received and 990 analysed. The prevalence of moderate to severe personal (N = 643; 64.9%) and work-related burnout (N = 428; 43.8%) were high. Having children, providing caseload midwifery care and working in a regional area were associated with low burnout. However, midwives registered for 5-10 years were more likely to report work and client-related burnout. Similarly, midwives reporting a lack of satisfaction with work-life balance were also more likely to report personal and work-related burnout. CONCLUSIONS: Family-friendly work environments that facilitate work-life balance can help to reduce the personal and organizational costs of burnout. Similarly, providing continuity of midwifery care in a caseload model can facilitate work-life balance and provide significant mental health benefits to participating midwives.

Factors associated with childbirth self-efficacy in Australian childbearing women.

BACKGROUND: Childbirth confidence is an important marker of women's coping abilities during labour and birth. This study investigated socio-demographic, obstetric and psychological factors affecting self-efficacy in childbearing women. METHOD: This paper presents a secondary analysis of data collected as part of the BELIEF study (Birth Emotions - Looking to Improve Expectant Fear). Women (n = 1410) were recruited during pregnancy (≤24 weeks gestation). The survey included socio-demographic details (such as age and partner support); obstetric details including parity, birth preference, and pain; and standardised psychological measures: CBSEI (Childbirth Self-efficacy Inventory), W-DEQ A (childbirth fear) and EPDS (depressive symptoms). Variables were tested against CBSEI first stage of labour sub-scales (outcome expectancy and self-efficacy expectancy) according to parity. RESULTS: CBSEI total mean score was 443 (SD = 112.2). CBSEI, W-DEQ, EPDS scores were highly correlated. Regardless of parity, women who reported low childbirth knowledge, who preferred a caesarean section, and had high W-DEQ and EPDS scores reported lower self-efficacy. There were no differences for nulliparous or multiparous women on outcome expectancy, but multiparous women had higher self-efficacy scores (p < .001). Multiparous women whose partner was unsupportive were more likely to report low self-efficacy expectancy (p < .05). Experiencing moderate pain in pregnancy was significantly associated with low self-efficacy expectancy in both parity groups, as well as low outcome expectancy in nulliparous women only. Fear correlated strongly with low childbirth self-efficacy. CONCLUSION: Few studies have investigated childbirth self-efficacy according to parity. Although multiparous women reported higher birth confidence significant obstetric and psychological differences were found. Addressing women's physical and emotional wellbeing and perceptions of the upcoming birth may highlight their level of self-efficacy for birth. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17(th) May 2012.

Effects of a midwife psycho-education intervention to reduce childbirth fear on women's birth outcomes and postpartum psychological wellbeing.

BACKGROUND: High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention. METHOD: Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here. RESULTS: 1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the 'decision aid' helped reduce their fear (53 % vs 37 %, p = 0.02). CONCLUSION: Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012.

Negotiating Care in the Special Care Nursery: Parents' and Nurses' Perceptions of Nurse-Parent Communication.

OBJECTIVE: Nursing staff are an important source of support for parents of a hospitalized preterm infant. This study aimed to describe parents' and nurses' perceptions of communicating with each other in the context of the special care nursery. METHOD: A qualitative descriptive design was employed. Thirty two parents with a newborn admitted to one of two special care nurseries in Queensland, Australia participated, and 12 nurses participated in semi-structured interviews. Thematic analysis was used to analyze the interviews. RESULTS: Nurses and parents focused on similar topics, but their perceptions differed. Provision of information and enabling parenting were central to effective communication, supported by an appropriate interpersonal style by nurses. Parents described difficulties accessing or engaging nurses. Managing enforcement of policies was a specific area of difficulty for both parents and nurses. CONCLUSION: The findings indicated a tension between providing family-centered care that is individualized and based on family needs and roles, and adhering to systemic nursery policies.

Prevalence of childbirth fear in an Australian sample of pregnant women.

BACKGROUND: Childbirth fear is reported to affect around 20% of women. However reporting on levels of symptom severity vary. Unlike Scandinavian countries, there has been limited focus on childbirth fear in Australia. The aim of this paper is to determine the prevalence of low, moderate, high and severe levels of childbirth fear in a large representative sample of pregnant women drawn from a large randomised controlled trial and identify demographic and obstetric characteristics associated with childbirth fear. METHOD: Using a descriptive cross-sectional design, 1,410 women in their second trimester were recruited from one of three public hospitals in south-east Queensland. Participants were screened for childbirth fear using the Wijma Delivery Expectancy/Experience Questionnaire Version A (WDEQ-A). Associations of demographic and obstetric factors and levels of childbirth fear between nulliparous and multiparous women were investigated. RESULTS: Prevalence of childbirth fear was 24% overall, with 31.5% of nulliparous women reporting high levels of fear (score ≥ 66 on the WDEQ-A) compared to 18% of multiparous women. Childbirth fear was associated with paid employment, parity, and mode of last birth, with higher levels of fear in first time mothers (p < 0.001) and in women who had previously had an operative birth (p < 0.001). CONCLUSION: Prevalence of childbirth fear in Australian women was comparable to international rates. Significant factors associated with childbirth fear were being in paid employment, and obstetric characteristics such as parity and birth mode in the previous pregnancy. First time mothers had higher levels of fear than women who had birthed before. A previous operative birth was fear provoking. Experiencing a previous normal birth was protective of childbirth fear.

A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women.

BACKGROUND: Childbirth fear is associated with increased obstetric interventions and poor emotional and psychological health for women. The purpose of this study is to test an antenatal psycho-education intervention by midwives in reducing women's childbirth fear. METHODS: Women (n = 1,410) attending three hospitals in South East Queensland, Australia, were recruited into the BELIEF trial. Participants reporting high fear were randomly allocated to intervention (n = 170) or control (n = 169) groups. All women received a decision-aid booklet on childbirth choices. The telephone counseling intervention was offered at 24 and 34 weeks of pregnancy. The control group received usual care offered by public maternity services. Primary outcome was reduction in childbirth fear (WDEQ-A) from second trimester to 36 weeks' gestation. Secondary outcomes were improved childbirth self-efficacy, and reduced decisional conflict and depressive symptoms. Demographic, obstetric & psychometric measures were administered at recruitment, and 36 weeks of pregnancy. RESULTS: There were significant differences between groups on postintervention scores for fear of birth (p < 0.001) and childbirth self-efficacy (p = 0.002). Decisional conflict and depressive symptoms reduced but were not significant. CONCLUSION: Psycho-education by trained midwives was effective in reducing high childbirth fear levels and increasing childbirth confidence in pregnant women. Improving antenatal emotional well-being may have wider positive social and maternity care implications for optimal childbirth experiences.

'Be our guest': challenges and benefits of using 'family conversations' to collect qualitative data about infant feeding and parenting.

AIMS AND OBJECTIVES: To describe the use of family conversations as a data collection strategy in a study that aimed to explore how 'social context' impacts on the infant feeding and early parenting choices of first-time mothers. Specifically, the authors aim to describe the challenges and benefits of facilitating 'family conversations' and the importance of considering the needs of the researcher and the research participants in the data collection process. BACKGROUND: Breastfeeding is endorsed by the World Health Organisation as a key health promotion strategy, and yet many women in Australia cease breastfeeding (either fully or partially) before the recommended time frame of six months. Engaging with and interviewing families is a well-established research strategy, but interviewing the family as a whole has rarely been used as a part of breastfeeding research. DESIGN: A component of a study, conducted in Sydney, Australia, was to use 'family conversations' to ascertain the views and beliefs that are held by those in the first-time mother's social network and how these impact on her experience of mothering and associated decision-making. CONCLUSIONS: Being able to balance the needs of the researcher and the research participants is an important challenge that is a core component of conducting ethical research. RELEVANCE TO CLINICAL PRACTICE: This paper highlights the viability of 'family conversations' as a data collection method for midwifery and nursing research and the need for midwives and child and family health nurses to more actively engage with a woman's support network with education and other strategies to assist in creating an environment for new mothers that is conducive to the continuation of breastfeeding and thriving as a mother.

What do women in Australia want from their maternity care: A scoping review.

BACKGROUND: Just over 300,000 women give birth in Australia each year. It is important for health care providers, managers, and policy makers know what women want from their care so services can be provided appropriately. This review is a part of the Midwifery Futures Project, which aims to prepare the midwifery workforce to best address the needs of women. The aim of this review was to describe and analyse current literature on the maternity care needs of women in Australia. METHODS: A scoping review methodology was used, guided by the Joanna Briggs Institute framework. A systematic search of the literature identified 9023 studies, and 59 met inclusion criteria: being peer-reviewed research focusing on maternity care needs, conducted in Australian populations, from 2012 to 2023. The studies were analysed using inductive content analysis. RESULTS: Four themes were developed: Continuity of care, being seen and heard, being safe, and being enabled. Continuity of care, especially a desire for midwifery continuity of care, was the central theme, as it was a tool supporting women to be seen and heard, safe, and enabled. CONCLUSION: This review highlights that women in Australia consistently want access to midwifery continuity of care as an enabler for addressing their maternity care needs. Transforming Australian maternity care policy and service provision towards continuity would better meet women's needs.

Study protocol for reducing childbirth fear: a midwife-led psycho-education intervention.

BACKGROUND: Childbirth fear has received considerable attention in Scandinavian countries, and the United Kingdom, but not in Australia. For first-time mothers, fear is often linked to a perceived lack of control and disbelief in the body's ability to give birth safely, whereas multiparous women may be fearful as a result of previous negative and/or traumatic birth experiences. There have been few well-designed intervention studies that test interventions to address women's childbirth fear, support normal birth, and diminish the possibility of a negative birth experience. METHODS/DESIGN: Pregnant women in their second trimester of pregnancy will be recruited and screened from antenatal clinics in Queensland, Australia. Women reporting high childbirth fear will be randomly allocated to the intervention or control group. The psycho-educational intervention is offered by midwives over the telephone at 24 and 34 weeks of pregnancy. The intervention aims to review birth expectations, work through distressing elements of childbirth, discuss strategies to develop support networks, affirm that negative childbirth events can be managed and develop a birth plan. Women in the control group will receive standard care offered by the public funded maternity services in Australia. All women will receive an information booklet on childbirth choices. Data will be collected at recruitment during the second trimester, 36 weeks of pregnancy, and 4-6 weeks after birth. DISCUSSION: This study aims to test the efficacy of a brief, midwife-led psycho-education counselling (known as BELIEF: Birth Emotions - Looking to Improve Expectant Fear) to reduce women's childbirth fear. 1) Relative to controls, women receiving BELIEF will report lower levels of childbirth fear at term; 2) less decisional conflict; 3) less depressive symptoms; 4) better childbirth self-efficacy; and 5) improved health and obstetric outcomes. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875.

Research priorities of midwives: a Delphi study.

The aim of this study was to identify the research priorities of midwives at Gold Coast Hospital (GCH), South East Queensland, Australia. It was also hoped that the study would help foster a culture of inquiry and reflection. Establishing and maintaining a research culture is essential to the provision of high quality maternity services. A two phase Delphi design was used. Fifty eight midwives participated in round one (50 per cent response rate) and 54 in round two (60 per cent response rate). Midwives identified post dates induction of labour and work place culture as areas of research interest.

The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography.

BACKGROUND: International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors. AIM: To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making. METHODS: We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was. FINDINGS: CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour. DISCUSSION AND CONCLUSION: Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

Sex, condoms and sexually transmissible infections: a qualitative study of sexual health in young Australian men.

Young males have a key role in shaping contraceptive use in a sexual relationship, yet often remain the invisible partner in safe sex promotion. This article describes a conceptual model of STI risk and condom use based on the perceptions and experiences of condom use in a group of young Australian males. An explorative descriptive design was used to conceptualize participants' condom use histories into an organized description of behavior. Forty-two semi-structured interviews were conducted with a purposive sample of males aged 15 to 25 years over an 18 month period. A sequential analytical process of data immersion, coding, and category generation was used to identify personal meanings, motivations, and contextual factors associated with condom use and non-use. Three primary discourses associated with young males' perceptions of STI risk and responding approach to condom use constructed personal commitment to sexual safety as dynamic, context-dependent, and outcome-driven (pregnancy versus STIs as the primary motivator of condom use). A regretful discourse associated with experiences of, or suspected unwanted outcomes, also emerged through changes in risk appraisals and safe sex intentions and behavior. Interventions to increase condom use should go beyond the traditional focus on risky behavior and disease prevention frameworks by addressing the contextual influences on personal risk appraisals and deliver innovative messages to reduce negative social meanings associated with condom use.

Surviving, not thriving: a qualitative study of newly qualified midwives' experience of their transition to practice.

AIM AND OBJECTIVES: The study explored the experiences of newly qualified midwives and described the factors that facilitated or constrained their development during the transition from student to registered midwife. BACKGROUND: Knowledge of the transition to midwifery practice remains limited. DESIGN AND METHOD: A qualitative descriptive approach was used. Sixteen graduates from one Australian University participated in a tape-recorded interview. Thematic analysis was used to analyse the data set. RESULTS: The metaphor of 'The Pond', an environment that consists of layers of life and can be both clear and peaceful or murky and infested, was used to describe new midwives perceptions of the context and culture of hospital-based maternity care. For some, 'The Pond' was a harsh environment that often became toxic. The 'Life-raft' metaphor was used to describe the importance of midwife-to-midwife relationships. The theme of 'Swimming' captured the consequence of positive interactions with colleagues and a supportive environment, whilst 'Sinking' described the consequence of poor relationships with midwives and a difficult working environment. CONCLUSION: The study highlights the importance of positive midwife-to-midwife relationships on the transition from student to registered midwife. There was also evidence that continuity with women and midwifery colleagues enhanced confidence and restored faith in normal birth. At the same time, it was clear that the midwifery culture of some institutions remains highly contested with midwives struggling to provide woman-centred care and often challenged by the risk-averse nature of maternity care. RELEVANCE TO CLINICAL PRACTICE: Whilst further work is required, the findings provide a deeper understanding of individual midwives' transition period. The importance of forming longitudinal relationships not only with women but with midwifery colleagues is highlighted. Developing continuity models that adequately support graduates and student's needs are likely to assist in addressing practices issues in both the academic and clinical setting.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice.

BACKGROUND: The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring. AIM: To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring. METHODS: Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed. FINDINGS: Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible. DISCUSSION AND CONCLUSION: Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.

"I'm not doing what I should be doing as a midwife": An ethnographic exploration of central fetal monitoring and perceptions of clinical safety.

BACKGROUND: Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common. AIM: This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system. METHODS: An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours. FINDINGS: The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system. DISCUSSION: The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety. CONCLUSION: This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.

A Western Australian survey of breastfeeding initiation, prevalence and early cessation patterns.

This paper reports on current initiation and prevalence rates, in Western Australia, differentiating 'any' breastfeeding with 'exclusive' breastfeeding whilst exploring patterns and reasons for stopping breastfeeding. The results presented are part of a larger study examining women's perceptions of care and wellbeing in the early postnatal period. A cross sectional survey was used to examine infant feeding practices during the hospital stay and at 9 weeks post birth from Western Australian women with a registered live birth between February and June 2006. Data obtained from 2,669 women revealed a 93% (n = 2,472) initiation rate of any breastfeeding. More multiparous women (73.5%) were exclusively breastfeeding in hospital compared to primiparous women (65.2%), which decreased to 57.1 and 49.2%, respectively at 9 weeks. Of those who had ceased by 9 weeks, more multiparous women (71.1%) ceased before 3 weeks. Reasons cited for ceasing in order of frequency were insufficient milk supply, infant related reasons, pain and discomfort and emotional reasons. Younger maternal age, primiparous women, lower maternal education levels, offering a combination of breast milk and formula in hospital and caesarean birth were significant independent predictors of early cessation. Although initiation rates including "any" breast milk are meeting NHMRC dietary guidelines of 90%, the 60% target of exclusive breastfeeding is not being achieved for 3 months or in fact at 9 weeks. Targeted support for at risk groups such as younger, less well-educated, primiparous women must continue. Evidence based policies to protect breastfeeding must address the practice of offering formula to breastfed infants in hospital and the impact of increasing interventions such as caesarean births.