"It's all about cultural understanding": A reflexive thematic analysis of women's experiences at a dedicated refugee midwifery group practice service.

BACKGROUND: Inequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background. OBJECTIVE: To explore and describe women's experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service. DESIGN: Qualitative exploratory descriptive study using focus group discussions and interpreters. SETTING: The study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia. METHODS: We conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women's perspectives and generate informed meanings of experiences of care. RESULTS: We generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care. CONCLUSION: The service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.

A systematic review of the cost-effectiveness of maternity models of care.

OBJECTIVES: In this systematic review, we aimed to identify the full extent of cost-effectiveness evidence available for evaluating alternative Maternity Models of Care (MMC) and to summarize findings narratively. METHODS: Articles that included a decision tree or state-based (Markov) model to explore the cost-effectiveness of an MMC, and at least one comparator MMC, were identified from a systematic literature review. The MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases were searched for papers published in English, Arabic, and French. A narrative synthesis was conducted to analyse results. RESULTS: Three studies were included; all using cost-effectiveness decision tree models with data sourced from a combination of trials, databases, and the literature. Study quality was fair to poor. Each study compared midwife-led or doula-assisted care to obstetrician- or physician-led care. The findings from these studies indicate that midwife and doula led MMCs may provide value. CONCLUSION: The findings of these studies indicate weak evidence that midwife and doula models of care may be a cost-effective or cost-saving alternative to standard care. However, the poor quality of evidence, lack of standardised MMC classifications, and the dearth of research conducted in this area are barriers to conclusive evaluation and highlight the need for more research incorporating appropriate models and population diversity.

How midwives facilitate informed decisions in the third stage of labour - an exploration through portraiture.

PROBLEM: Midwifery philosophy promotes informed decision-making. Despite this, midwives report a lack of informed decision-making in standard maternity care systems. BACKGROUND: Previous research has shown a woman's ability to make informed decisions within her maternity care significantly impacts her childbearing experience. When informed decision-making is facilitated, women report positive experiences, whereas when lacking, there is an increased potential for birth trauma. AIM: To explore midwives' experiences of facilitating informed decision-making, using third-stage management as context. METHODS: Five midwives from Victoria, Australia, were interviewed about their experiences with informed decision-making. These interviews were guided by portraiture methodology whereby individual narrative portraits were created. This paper explores the shared themes among these five portraits. FINDINGS: Five individual narrative portraits tell the stories of each midwife, providing rich insight into their philosophies, practices, barriers and enablers of informed decision-making. These are then examined as a whole dataset to explore shared themes, and include; 'informed decision-making is fundamental to midwifery practice' 'the system', and 'navigating the system'. The system contained the sub-themes; hierarchy in hospitals, the medicalisation of birth, and the impact on midwifery practice, and 'navigating the system' - contained; safety of the woman and safety of the midwife, and the gold-standard of midwifery. DISCUSSION AND CONCLUSION: Midwives in this study valued informed decision-making as fundamental to their philosophy but also faced barriers in their ability to facilitate it. Barriers to informed decision-making included: power-imbalances; de-skilling in physiological birth; fear of blame, and interdisciplinary disparities. Conversely enablers included continuity models of midwifery care, quality antenatal education, respectful interdisciplinary collaboration and an aim toward a resurgence of fundamental midwifery skills.

Effectiveness of a midwife-led continuity of care model on birth outcomes and maternal mental health in vulnerable women: study protocol for a randomised controlled trial with an internal pilot, process evaluation and economic analysis.

INTRODUCTION: Women from social disadvantage are at greater risk of poor birth outcomes. The midwife-led continuity of care (MCC) model, which offers flexible and relational care from a small team of midwives, has demonstrated improved birth outcomes. In the general population, the impact of MCC on socially disadvantaged women and on birth outcomes is still unclear. This protocol describes a pragmatic evaluation of the MCC model in a socially disadvantaged population. METHODS AND ANALYSIS: An open-labelled individual prospective randomised controlled trial with an internal pilot, process evaluation and economic analysis, from 1 April 2022 to 31 March 2024.Women will be randomly allocated to MCC or standard care as part of usual midwifery practice. Participants and midwives will not be blinded, but researchers will be. An internal pilot will test the feasibility of this process.Participants are those randomised into MCC or standard care, who consent to participate in one of two Born in Bradford (BiB) birth cohort studies. Outcomes are taken from routinely linked health data, supplemented by additional data capture. The sample size is fixed by the capacity of MCC teams, commissioning duration and numbers recruited into the cohort. The estimated maximum fixed sample size is 1,410 pregnancies (minimum 734).Intention to treat (ITT) analysis will be undertaken to assess the impact of MCC on two independent primary outcomes. An economic evaluation will explore the impact on health resource use and a process evaluation will explore fidelity to the MCC model, and barriers/facilitators to implementation from midwives' and women's perspectives. ETHICS AND DISSEMINATION: Ethical approval has been obtained for the randomisation in midwifery practice, use of the cohort data for evaluation and for the process evaluation. Findings will be published in peer-reviewed journals, presented at conferences and translated into policy briefings. TRIAL REGISTRATION NUMBER: IsRCTNhttps://doi.org/10.1186/ISRCTN31836167.

Determinants of maternal mortality in south-western Nigeria: Midwives' perceptions.

BACKGROUND: Maternal mortality remains one of Nigeria's most significant public health challenges. In order to address this issue sustainably, it is necessary to consider the perceptions of all stakeholders involved, including midwives. OBJECTIVES: To examine the determinants of maternal mortality in south-western Nigeria from the midwife's perspective. DESIGN: A cross-sectional study was employed using mixed methods with a semi-structured questionnaire and an in-depth interview guide. PARTICIPANTS: Quantitative data were obtained from 215 midwives using a convenience sampling technique. Qualitative data were obtained from 25 midwives from five government health centres, selected using a stratified sampling technique. METHODS: Quantitative data were analysed using SPSS Version 20 using descriptive and inferential statistics with 95 % confidence intervals, while qualitative data were analysed using thematic analyses. FINDINGS: The mean age and work experience of the participants were 35.2 ± 9.3 years and 8.4 ± 7.0 years, respectively. The midwives perceived that the main determinants of maternal mortality were postpartum haemorrhage (86.5 %), hypertensive disorder in pregnancy (80.9 %), mismanagement at mission homes/traditional birth attendant centres (MH/TBAs) (79.1 %) and sepsis (70.1 %). Some of the priority target areas to improve the well-being of pregnant women as identified by the midwives, were increased awareness of pregnancy danger signs (97 %), destigmatising caesarean section (CS) (96 %), regulation of MH/TBAs (92 %), and increased accessibility of hospitals (84 %). Findings from the qualitative data also affirmed that regulating MH/TBAs, destigmatising CS and subsidising healthcare expenses were prerequisites to curbing maternal mortality. Inferential analysis revealed that determinants such as unsafe abortion (p < 0.001), ectopic pregnancy (p = 0.001), domestic violence (p = 0.023), malaria (p = 0.029), short interbirth interval (p = 0.03), and patients' negative perceptions of CS delivery (p = 0.036) were more commonly perceived to be associated with maternal mortality by younger midwives (age 17-34 years) compared with older midwives. KEY CONCLUSION: The results indicate that resolving the maternal mortality crisis sustainably in Nigeria will require increased accessibility to basic health care and health promotion campaigns to counteract unhelpful sociocultural norms. IMPLICATIONS FOR PRACTICE: Future interventions must be tailored to address both traditional and emerging causes of maternal mortality in southwestern Nigeria.

Developing the midwifery Unit Self-Assessment (MUSA) Framework: A mixed methods study in six European midwifery units.

OBJECTIVE: Evidence indicates that midwifery units are associated with improved health outcomes and experiences; however, there are barriers to their development and scale-up. Guidelines are crucial to their implementation, ensuring that they are developed and integrated sustainably and safely. This study aimed to evaluate and explore the use of a self-assessment tool and improvement process for midwifery units in Europe. METHODS: A mixed methods study was conducted with six midwifery units located in Europe. Quantitative and qualitative data were collected and analysed concurrently, and each informed the other, making the approach both interactive and iterative. The six midwifery units were invited to complete the self-assessment tool, the responses of which were analysed descriptively, and implement an improvement process into practice. Interviews were conducted with midwives using the tool and analysed thematically. RESULTS: Findings indicate benefits and potential feasibility of an improvement process for midwifery units, and suggest that the self-assessment tool is a generative and reflexive practice for midwives. However, issues were identified around limitations of the tool, structural barriers and professional autonomy. Midwifery units require a framework to guide and support their implementation, improvement and scale-up. CONCLUSION: Results highlight the need for more consideration of how macro-level barriers, encompassing social, legal and political dimensions of maternity care, factor locally in the implementation and scale-up of midwifery units. More research is needed to evaluate the feasibility and outcomes of implementing a self-assessment and improvement framework in midwifery units across Europe.

Black mothers' birthing experiences: in search of birthing justice.

OBJECTIVES: Previous studies have suggested that often, Black mothers' birthing experiences are not what they expected because of how they were treated by healthcare providers during labor and birth. Our goal in this study was to ask Black mothers who had recently given birth about the quality of their birthing experiences as well as their level of respect from, trust in, and satisfaction with their maternity healthcare providers. DESIGN: This study gathered data from Black mothers (N = 209) who had given birth within the past two years, using a cross-sectional online survey measuring several variables about the birthing experience including types of healthcare provider communication, provider respect for the mother, trust, birth satisfaction, and emotional responses to birth. RESULTS: Provider-centered communication, although preferred by some mothers, was associated with lower birth satisfaction and stronger negative emotions whereas positive birth satisfaction was linked to patient-centered communication which resulted in positive emotions. While most mothers reported overall satisfaction with their birth experience, nearly half reported experiencing some degree of disrespect from their healthcare providers during labor and birth. Moreover, trust and respect mediated the relationship for patient-centered communication with positive emotion and birth satisfaction. Over one-third of participants gave birth with a certified nurse midwife attending. There were no differences in perception of being respected or the quality of birth given the professional identity of the provider as an Obstetrician/Gynecologist or as a midwife. The advice suggested by Black mothers for their healthcare providers was instructive in identifying ways those providers could better serve their patients during birth. CONCLUSION: This study showed that there is still additional work that needs to be done for racial equity and respect during birth. Practical implications for addressing health inequities are discussed.

Strong Start Innovation: Equitable Outcomes Across Public and Privately Insured Clients Receiving Birth Center Care.

INTRODUCTION: The Birth Center model of care is a health care delivery innovation in its fourth decade of demonstration across the United States. The purpose of this research was to evaluate the model's potential for decreasing poverty-related health disparities among childbearing families. METHODS: Between 2013 and 2017, 26,259 childbearing people received care within the 45 Center for Medicare and Medicaid Innovation Strong Start birth center sites. Secondary analysis of the prospective American Association of Birth Centers Perinatal Data Registry was conducted. Descriptive statistics described sociobehavioral, medical risk factors, and core clinical outcomes to inform the logistic regression model. Privately insured consumers were independently compared with 2 subgroups of Medicaid beneficiaries: Strong Start enrollees (midwifery-led care with peer counselors) and non-Strong Start Medicaid beneficiaries (midwifery-led care without peer counselors). RESULTS: After controlling for medical risk factors, Strong Start Medicaid beneficiaries achieved similar outcomes to privately insured consumers with no significant differences in maternal or newborn outcomes between groups. Perinatal outcomes included induction of labor (adjusted odds ratio [aOR], 0.86; 95% CI 0.61-1.13), epidural analgesia use (aOR, 1.00; 95% CI, 0.68-1.48), cesarean birth (aOR, 1.16; 95% CI, 0.87-1.53), exclusive breastfeeding on discharge (aOR, 1.11; 95% CI, 0.48-2.56), low Apgar score at 5 minutes (aOR, 1.23; 95% CI, 0.86-1.83), low birth weight (aOR, 1.12; 95% CI, 0.77-1.64), and antepartum transfer of care after the first prenatal appointment (aOR, 1.53; 95% CI, 0.97-2.40). Medicaid beneficiaries who were not enrolled in the Strong Start midwifery-led, peer counselor program demonstrated similar results except for having higher epidural analgesia use (aOR, 1.30; 95% CI, 1.10-1.53) and significantly lower exclusive breastfeeding on discharge (aOR, 0.57; 95% CI, 0.40-0.81) than their privately insured counterparts. DISCUSSION: The midwifery-led birth center model of care complemented by peer counselors demonstrated a pathway to achieve health equity.

Dene, métis and inuvialuit peoples' voices on the impact of Canada's perinatal transport and non-medical escort policy in their communities: an outcome assessment approach and narrative literature review.

Historically, there is a documented lack of support for women leaving their communities to give birth. Due to an over-emphasis on risk discourse (no distinction between low- or high-risk pregnancies with options to birth at home, the large geographical distances to regional centres within circumpolar regions, remoteness of communities, lack of qualified staff, and limited resources), women are forced to travel great distances to give birth. In Canada until 2017, women travelled alone or bore the burden of paying out of pocket for someone to travel with them for support with the births of their babies. A recent policy change has allowed for one paid escort to accompany a pregnant woman. The purpose of this paper is to provide an outcome assessment of the perinatal transport and non-medical escort policy implemented by the federal government in Canada. The paper utilises a narrative literature review along with preliminary Indigenous photovoice results to illuminate the perspectives of Indigenous families. There are numerous challenges women face when travelling for birth including feelings of loneliness and fear, stress and separation from their children, lack of community connection, financial concerns, and a loss of self-determination. Women are given an opportunity in decision-making about who will travel with them as an escort. This does little to address the disparity of delivering their babies away from their families and communities, the burden of figuring out who cares for the children at home, and the impact their absences have on health of their families. Although, additional support has been provided for birthing women in northern Canada, there continues to be little effort to return to community birthing creating safety for Indigenous families through traditional practices, Indigenous midwifery, and community ceremonies and changing the disproportionate burden of poor outcomes experienced by Indigenous women.

Inequities in quality perinatal care in the United States during pregnancy and birth after cesarean.

OBJECTIVE: High-quality, respectful maternity care has been identified as an important birth process and outcome. However, there are very few studies about experiences of care during a pregnancy and birth after a prior cesarean in the U.S. We describe quantitative findings related to quality of maternity care from a mixed methods study examining the experience of considering or seeking a vaginal birth after cesarean (VBAC) in the U.S. METHODS: Individuals with a history of cesarean and recent (≤ 5 years) subsequent birth were recruited through social media groups to complete an online questionnaire that included sociodemographic information, birth history, and validated measures of respectful maternity care (Mothers on Respect Index; MORi) and autonomy in maternity care (Mother's Autonomy in Decision Making Scale; MADM). RESULTS: Participants (N = 1711) representing all 50 states completed the questionnaire; 87% planned a vaginal birth after cesarean. The most socially-disadvantaged participants (those less educated, living in a low-income household, with Medicaid insurance, and those participants who identified as a racial or ethnic minority) and participants who had an obstetrician as their primary provider, a male provider, and those who did not have a doula were significantly overrepresented in the group who reported lower quality maternity care. In regression analyses, individuals identified as Black, Indigenous, and People of Color (BIPOC) were less likely to experience autonomy and respect compared to white participants. Participants with a midwife provider were more than 3.5 times more likely to experience high quality maternity care compared to those with an obstetrician. CONCLUSION: Findings highlight inequities in the quality of maternal and newborn care received by birthing people with marginalized identities in the U.S. They also indicate the importance of increasing access to midwifery care as a strategy for reducing inequalities in care and associated poor outcomes.

Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

OBJECTIVE: In most high-income countries, the cardiotocography and handheld Doppler device have replaced the Pinard stethoscope for intrapartum foetal monitoring. As a result, the skills required to use the Pinard are rapidly disappearing from midwifery. The aim of this study was thus to illuminate the knowledge before it is lost, by exploring the practice, skills and experience of Norwegian midwives familiar with the Pinard for intrapartum foetal monitoring. We included midwives who still regularly use the Pinard in their current practice in a variety of birth settings, and those who used the Pinard in the era prior to the introduction of the CTG. DESIGN: This study followed a qualitative descriptive design based on mainly focus group interviews, but also including one individual interview. The interviews explored the participants` perspective on their practice, skills and experience regarding the use of the Pinard for intrapartum foetal monitoring. Reflexive thematic analysis captured common patterns across the data, and contextualism was used as research paradigm. SETTING AND PARTICIPANTS: In total, 21 midwives with experience using the Pinard for intrapartum foetal monitoring were interviewed. The midwives were either retired and had experience using the Pinard from before the CTG became widespread; worked in an alongside midwifery unit that only oversees low-risk births; or worked in an obstetric unit in a university hospital with an active policy of using the Pinard for intrapartum foetal monitoring. FINDINGS: The analysis resulted in four main themes: "Practice and experience with the Pinard are related to context", "Skills with the Pinard come with work experience", "The Pinard reveals certain characteristics of foetal sound" and "Midwives` experience with the benefits of using the Pinard". The midwives considered the context for using the Pinard for intrapartum foetal monitoring relevant. The e availability of technology and applicable situations for using the Pinard influenced how and when they use the Pinard. They further underpinned training and work experience as important for feeling secure when using the Pinard, and this experience made them recognize normal and abnormal foetal sounds. Defining and characterizing these sounds appeared difficult for the midwives, however, and they hesitated and imitated the sound. The midwives felt that the Pinard is beneficial for both the labouring woman and the midwife, as the Pinard's features bring them closer to the labouring woman and help calm the birth suite. They also felt that the Pinard adds further information about the birth and birth process, such as foetal lie, rotation and descent. KEYCONCLUSIONS: Norwegian midwives' practice, and experiences in using the Pinard for intrapartum foetal monitoring are connected to context as technological development and applicable situations. The midwives explained that knowledge obtained through experience gives them skills to differentiate between normal and abnormal foetal sound characteristics, though they found it difficult to define the characteristics themselves. Using the Pinard stethoscope during birth calms the birth suite and brings the midwife closer to the labouring woman.

Secondary traumatic stress in iranian midwives: stimuli factors, outcomes and risk management.

BACKGROUND: The present qualitative study was conducted to explain the experiences of secondary traumatic stress (STS) and its related factors in midwives working in maternity wards. METHODS: Data were collected using semi-structured interviews with 11 midwives working in the maternity wards of hospitals in Urmia, Iran, through in-depth interviews with open-ended questions. Data were analyzed using the conventional content analysis approach. RESULTS: The results of data analysis led to the extraction of three themes, seven main categories, and 18 subcategories. The first theme was "STS stimuli," with the two categories of "Discriminatory approach to midwifery" and "The nature of the midwifery profession". The second theme was "Traumatic outcomes", which included the subcategories of "Psychological-emotional trauma", "Physical trauma" and "Social trauma". The third theme was "Risk management", which had the two subcategories of "Reactive approach" and "Proactive approach". CONCLUSIONS: The results showed that, in addition to the traumatic nature of events that midwives experience during work as the secondhand victims, factors such as governance-organizational structure, unbalanced distribution of power, and poor supportive laws undermine their professional role and provide conditions conducive to STS. Therefore, avoiding traumatic situations and scientific and skill self-empowerment were the most important strategies adopted by the midwives in this study to prevent risky situations and cope with the consequences of STS. The participation of midwifery stakeholders in policy-making and adopting supportive legislation in redefining the position and role of midwives can play a major role in reducing STS and sustaining their role and position in maternal care.

Using epidemiological and health economic measures to inform maternity staffing decisions: A guide.

BACKGROUND: There is growing concern around unnecessary intervention (particularly caesarean section) at birth in high-income countries. Caseload midwifery care aims to offset this, but is perceived to be costly to health services. AIM: To use epidemiological and health economic techniques to estimate health outcomes and cost-savings of different levels of equivalent full time (EFT) midwives working in caseload midwifery care. METHODS: Two simulations were conducted - one assuming 10 EFT midwives working in a caseload model, with 35 women per caseload, and one assuming 50 EFT midwives working in a caseload model, with 45 women per caseload. Both were based on a sample of 5000 women. The main model inputs included rates of health outcomes for women (caesarean section, epidural anaesthesia, and episiotomy) and infants (low birthweight and admissions to special care nursery (SCN) or neonatal intensive care unit (NICU)), and the cost savings associated with health outcome avoidance. FINDINGS: The first simulation estimated 27 fewer caesarean sections, 12 fewer epidurals, 12 fewer episiotomies, 10 fewer low birthweight births, and 23 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$1,874,715. The second simulation estimated 173 fewer caesarean sections, 76 fewer epidurals, 76 fewer episiotomies, 65 fewer low birthweight births, and 150 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$12,051,741. CONCLUSION: This study provides local-level decision-makers with a decision-tool to calculate the potentially avoidable health outcomes and cost savings associated with implementing caseload midwifery care in their own service.

Women's experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study.

BACKGROUND: Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. A measure to reverse this trend is to fully implement the Uganda Clinical Guidelines on care for mothers and newborns during pregnancy, delivery and the postnatal period. This study aimed to describe women's experiences of maternal and newborn health care services and support systems, focusing on antenatal care, delivery and the postnatal period. METHODS: We used triangulation of qualitative methods including participant observations, semi-structured interviews with key informants and focus group discussions with mothers. Audio-recorded data were transcribed word by word in the local language and translated into English. All collected data material were stored using two-level password protection or stored in a locked cabinet. Malterud's Systematic text condensation was used for analysis, and NVivo software was used to structure the data. FINDINGS: Antenatal care was valued by mothers although not always accessible due to transport cost and distance. Mothers relied on professional health workers and traditional birth attendants for basic maternal services but expressed general discontentment with spousal support in maternal issues. Financial dependency, gender disparities, and lack of autonomy in decision making on maternal issues, prohibited women from receiving optimal help and support. Postnatal follow-ups were found unsatisfactory, with no scheduled follow-ups from professional health workers during the first six weeks. CONCLUSIONS: Further focus on gender equity, involving women's right to own decision making in maternity issues, higher recognition of male involvement in maternity care and improved postnatal follow-ups are suggestions to policy makers for improved maternal care and newborn health in Buikwe District, Uganda.

Australian midwives and clinical investigation: Exploration of the personal and professional impact.

BACKGROUND: The purpose of regulation of health professionals is public protection. Concerns regarding professional conduct or midwifery care can lead to clinical investigation. Midwifery literature reveals midwives feel ill-equipped and unprepared for clinical investigation and experience stress and abreaction. AIM: To explore the lived experience of clinical investigation and identify the personal and professional impact on Australian midwives. METHOD: Semi-structured interviews of a purposive sample of Australian midwives. Data analysis was informed by a phenomenological conceptual framework derived from Husserl, Heidegger and Merleau-Ponty. FINDINGS: Twelve midwives were interviewed, with seven under current investigation. Discussion involved personal and professional experiences of three or more investigations each, over a period of three to five years. Most investigations were instigated by hospitals with two complaints from women. Seven participants were alleged negligent following adverse neonatal outcomes and five had misconduct allegations. Midwives were employed or in private practice and half provided homebirth services. Themes included being safe, being connected, time and being, perception and well-being. DISCUSSION: The investigative process involves different health services, state and national bodies using varying powers and processes over protracted time periods. Participants discussed aspects such as disrespect, inequity, powerlessness, silence and ostracization. Midwives who successfully navigated clinical investigation developed resilience through reflection on clinical practice in a culture of safety. CONCLUSION: The process of regulating midwives, designed to protect the Australian public, may be harming investigated midwives. Understanding the personal and professional impact of clinical investigation needs to underpin midwifery education, clinical practice, inform policy and regulatory reform.

Barriers and enablers for midwives to use the Nursing and Midwifery Board of Australia's Endorsement for scheduled medicines for midwives.

BACKGROUND: In 2010, the Nursing and Midwifery Board of Australia introduced a new registration standard: Endorsement for scheduled medicines for midwives. The endorsement enables midwives to provide women with Medicare-rebatable care, prescribe relevant medications, and order relevant Medicare-rebatable diagnostics. Translating endorsement education into clinical midwifery practice has been slow, indicating the presence of barriers affecting midwives' ability to use this standard, despite it increasing their scope for service provision. AIM: To discover the mechanisms affecting midwives' ability to work to full scope of practice after completing a programme of study leading to endorsement. METHODS: An observational (non-experimental) design was used. Midwives who had completed an education programme leading to endorsement were invited to complete a survey. Descriptive statistics were used to analyse the quantitative questions and content analysis was conducted on the qualitative data. FINDINGS: Results indicated that barriers - such as the limitations of Medicare provisions for endorsed midwives and a general lack of support for the role - restrict endorsed midwives' ability to provide quality maternity services. Having some form of support for the role may act as an enabler, in addition to midwives having personal determination and confidence in their ability to use the endorsement. Recommendations to strengthen the endorsed midwife's role include facilitating endorsement use in the public sector, relaxing Medicare Benefit Schedule and Pharmaceutical Benefit Scheme restrictions, raising awareness of the role and scope, and improving midwives' pre-endorsement preparation. CONCLUSION: This study highlights the need for an all-of-system approach to support and develop the endorsed midwife's role.

An exploration of midwives' role in the promotion and provision of antenatal influenza immunisation: A mixed methods inquiry.

PROBLEM: No South Australian study has previously investigated the role of midwives in the promotion and provision of antenatal influenza immunisation. BACKGROUND: Influenza acquired in pregnancy can have serious sequalae for both mother and foetus. Recent studies have demonstrated that influenza vaccine in pregnancy is both safe and effective. Despite this, evidence suggests that vaccine uptake in pregnancy is suboptimal in both Australia and worldwide. AIM: The aim of this study was to investigate the role of midwives in the promotion and provision of antenatal influenza vaccine and, to provide a statistical and thematic description of the barriers and enablers midwives encounter. METHODS: This mixed method study incorporated a cross sectional on-line survey and in-depth interviews conducted with midwives, employed in urban and regional South Australia. FINDINGS: Quantitative data were available for 137 midwives and 10 midwives participated in the interviews. Recruitment for the interview phase was through the last question on the survey. Whilst all midwives indicated that education and vaccine promotion were part of their role, immunisation knowledge varied between Registered Nurse/Midwives (RM/RN) 80% and Registered Midwives (RM) 48.90% (p = 0.001). Quantitative data showed that only 43% of midwives felt sufficiently educated to provide the vaccine. Midwives who had received formal immunisation training were more likely to recommend the vaccine 93.7% (p = 0.001). Qualitative data confirmed these results and identified the lack of immunisation education as a barrier to practise. CONCLUSION: Midwives identified an immunisation knowledge deficit. Midwives who had received immunisation education were more likely to actively promote and provide the vaccine to pregnant women. These findings indicate the need for more immunisation education of midwives in both tertiary and practice settings.

Oral Health Knowledge, Practices, and Awareness of Oral Health Guidelines and Dental Coverage Policies among Midwives.

INTRODUCTION: Good oral health during the prenatal period translates into better oral and overall health for women and their infants. Although the importance of oral health during pregnancy is well established, oral health assessments are not routinely included in prenatal care visits. The purpose of this study was to explore prenatal care providers' practices regarding oral health assessments and identify reasons for the gap in oral health integration in prenatal care. Data were gathered from midwives in Virginia, United States. Information on midwives' knowledge about oral health, education, practices, and awareness of oral health guidelines and the pregnancy-related Medicaid dental benefit policy in Virginia was collected. METHODS: An online survey was distributed to midwives practicing in Virginia through their state-level professional organization. The data were collected online, and descriptive data analyses were conducted. RESULTS: A total of 30 midwives (mean age 51.9 years) participated in the survey for an overall response rate of 13.6%. Among survey participants, knowledge of oral health was high (score of 4.69 out of 5). Nearly 20% of participants reported receiving no education about oral health during professional training, and 72.4% reported no receipt of continuing education about oral health in the past year. Although 86% of the participants reported discussing oral health in clinical practice, only 10.3% reported conducting oral health assessments. Awareness of Virginia's Medicaid dental benefit policy was high (75.9%), but less than half of the participants were aware of oral health guidelines (44.1%). Although many midwives did not conduct oral health assessments, 79.3% reported that they provided oral health referrals to pregnant patients. DISCUSSION: Enhancing and integrating education about oral health in the academic curriculum for midwives and providing them with opportunities for continuing education about oral health can improve their engagement with oral health. Sharing of evidence-based guidelines through organizational newsletters, meetings, and other venues can be ways to increase awareness of new guidelines and health coverage benefits among midwives.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries.

BACKGROUND: The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD: We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS: The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS: The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.