Either 'a blessing in disguise', or 'I couldn't get help,': Australian and Aotearoa NZ women's experiences of early infant feeding during COVID-19.

BACKGROUND: To manage the COVID-19 pandemic, public health restrictions and a rapid pivot to telehealth occurred. Peripartum services were significantly affected by a strained infrastructure. Decreased face to face access to health services and support affected maternal experiences and confidence internationally, yet little was reported with the Australian and Aotearoa New Zealand context. AIM: To explore the early parenting and infant feeding experiences of new mothers from Australia and Aotearoa New Zealand in the context of a pandemic. METHODS: An interpretive qualitative approach and thematic analysis obtained an in-depth understanding of the experiences of 27 mothers who gave birth during the first wave of the COVID-19 pandemic in 2020. FINDINGS: Australian and Aotearoa New Zealand women reported similar experiences, which varied contextually. Restrictions and requirements impacted favourably and unfavourably. Many women found the peace and space of social distancing an unexpected benefit and were proud of their achievements, whilst others shared feelings of isolation and distress. Some women felt they instinctively did what they needed to do. Experiences correlated with differing levels of self-efficacy. DISCUSSION: While many women relished the freedom from social obligations when faced with feeding challenges, there was general dissatisfaction with the level of support available. Care was fragmented, and health care needs were unmet, impacting feeding and parenting decisions and mental health. CONCLUSION: Access to timely and appropriate professional support is an important factor in establishing breastfeeding and developing parenting confidence, particularly in the context of a pandemic and should be a health policy priority.

Predictors and impact of women's breastfeeding self-efficacy and postnatal care in the context of a pandemic in Australia and Aotearoa New Zealand.

OBJECTIVE: To investigate predictors of breastfeeding self-efficacy, postnatal care experiences, and there subsequent impact on breastfeeding outcomes in Australia and Aotearoa New Zealand in the context of the COVID-19 pandemic. DESIGN: A cross-sectional online survey collected data between August and October 2020 with recruitment via social media. Quantitative data were analyzed using descriptive analyses, and linear and logistic regression analysis related to the Breastfeeding Self-Efficacy Scale-Short Form findings. Open text responses were analyzed using content analysis. FINDINGS: There were 1001 complete responses. Visitor restrictions impacted the woman's early parenting experience in both positive and negative ways. One third of participants stated their postnatal needs were not met with 82 stating that they had no postnatal care at all. During the first six weeks postnatal, 48.1% felt not very or not at all confident caring for their baby. Despite 94.3% of participants initiating breastfeeding, only 70% were exclusively breastfeeding at six weeks. The mean self-efficacy score was 49.98 suggesting the need for additional help, with first time mothers having a statistically significant lower score. DISCUSSION/CONCLUSION: Sub-optimal postnatal care and support negatively influence breastfeeding self-efficacy. Women desired additional help during the COVID-19 pandemic inclusive of support and education to meet their postnatal needs and exclusively breastfeed. IMPLICATIONS FOR PRACTICE: Women require appropriate and timely postnatal care and support to promote confidence in caring for baby and achieve their breastfeeding goals. Preferably this care should be provided face-to-face.

Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study.

BACKGROUND: Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear. AIM: To study the significance of relationships in rural midwifery and provide insights to inform midwifery education. METHODS/DESIGN: Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data. FINDINGS: Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships. CONCLUSIONS: To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice. IMPLICATIONS: Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education.

Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland.

OBJECTIVE: the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN: online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS: 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS: underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS: rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE: findings will inform the preparation of midwives for rural midwifery practice.

Evaluating Maternity Units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand-clinical outcomes.

OBJECTIVE: To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand. DESIGN: Prospective cohort study. PARTICIPANTS: 407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010-2011. All of the women planning a TMH birth were 'low risk', and 29 of the PMU cohort had identified risk factors. PRIMARY OUTCOMES: Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission. SECONDARY OUTCOMES: labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality. RESULTS: Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators. CONCLUSIONS: The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes.

Women׳s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand.

OBJECTIVE: to explore women׳s birthplace decision-making and identify the factors which enable women to plan to give birth in a freestanding midwifery-led primary level maternity unit rather than in an obstetric-led tertiary level maternity hospital in New Zealand. DESIGN: a mixed methods prospective cohort design. METHODS: data from eight focus groups (37 women) and a six week postpartum survey (571 women, 82%) were analysed using thematic analysis and descriptive statistics. The qualitative data from the focus groups and survey were the primary data sources and were integrated at the analysis stage; and the secondary qualitative and quantitative data were integrated at the interpretation stage. SETTING: Christchurch, New Zealand, with one tertiary maternity hospital and four primary level maternity units (2010-2012). PARTICIPANTS: well (at 'low risk' of developing complications), pregnant women booked to give birth in one of the primary units or the tertiary hospital. All women received midwifery continuity of care, regardless of their intended or actual birthplace. FINDINGS: five core themes were identified: the birth process, women׳s self-belief in their ability to give birth, midwives, the health system and birth place. 'Confidence' was identified as the overarching concept influencing the themes. Women who chose to give birth in a primary maternity unit appeared to differ markedly in their beliefs regarding their optimal birthplace compared to women who chose to give birth in a tertiary maternity hospital. The women who planned a primary maternity unit birth expressed confidence in the birth process, their ability to give birth, their midwife, the maternity system and/or the primary unit itself. The women planning to give birth in a tertiary hospital did not express confidence in the birth process, their ability to give birth, the system for transfers and/or the primary unit as a birthplace, although they did express confidence in their midwife. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: birthplace is a profoundly important aspect of women׳s experience of childbirth. Birthplace decision-making is complex, in common with many other aspects of childbirth. A multiplicity of factors needs converge in order for all those involved to gain the confidence required to plan what, in this context, might be considered a 'countercultural' decision to give birth at a midwife-led primary maternity unit.

An exploration of influences on women's birthplace decision-making in New Zealand: a mixed methods prospective cohort within the Evaluating Maternity Units study.

BACKGROUND: There is worldwide debate surrounding the safety and appropriateness of different birthplaces for well women. One of the primary objectives of the Evaluating Maternity Units prospective cohort study was to compare the clinical outcomes for well women, intending to give birth in either an obstetric-led tertiary hospital or a free-standing midwifery-led primary maternity unit. This paper addresses a secondary aim of the study--to describe and explore the influences on women's birthplace decision-making in New Zealand, which has a publicly funded, midwifery-led continuity of care maternity system. METHODS: This mixed method study utilised data from the six week postpartum survey and focus groups undertaken in the Christchurch area in New Zealand (2010-2012). Christchurch has a tertiary hospital and four primary maternity units. The survey was completed by 82% of the 702 study participants, who were well, pregnant women booked to give birth in one of these places. All women received midwifery-led continuity of care, regardless of their intended or actual birthplace. RESULTS: Almost all the respondents perceived themselves as the main birthplace decision-makers. Accessing a 'specialist facility' was the most important factor for the tertiary hospital group. The primary unit group identified several factors, including 'closeness to home', 'ease of access', the 'atmosphere' of the unit and avoidance of 'unnecessary intervention' as important. Both groups believed their chosen birthplace was the right and 'safe' place for them. The concept of 'safety' was integral and based on the participants' differing perception of safety in childbirth. CONCLUSIONS: Birthplace is a profoundly important aspect of women's experience of childbirth. This is the first published study reporting New Zealand women's perspectives on their birthplace decision-making. The groups' responses expressed different ideologies about childbirth. The tertiary hospital group identified with the 'medical model' of birth, and the primary unit group identified with the 'midwifery model' of birth. Research evidence affirming the 'clinical safety' of primary units addresses only one aspect of the beliefs influencing women's birthplace decision-making. In order for more women to give birth at a primary unit other aspects of women's beliefs need addressing, and much wider socio-political change is required.