Providing maternity care for disadvantaged women in Aotearoa New Zealand: The impact on midwives.

BACKGROUND: Health inequities and socio-economic disadvantage are causes for concern in Aotearoa New Zealand. Becoming pregnant can increase a woman's vulnerability to poverty, with the potential for an increase in multiple stressful life events. Providing midwifery care to women living in socio-economic deprivation has been found to add additional strains for midwives. Exploring the perspectives of the midwives providing care to women living with socio-economic deprivation can illuminate the complexities of maternity care. AIM: To explore the impact on midwives when providing care for socio-economically disadvantaged women in Aotearoa New Zealand. METHOD: Inductive thematic analysis was used to analyse an open-ended question from a survey that asked midwives to share a story around maternal disadvantage and midwifery care. FINDINGS: A total of 214 stories were received from midwives who responded to the survey. Providing care to disadvantaged women had an impact on midwives by incurring increased personal costs (time, financial and emotional), requiring them to navigate threats and uncertainty and to feel the need to remedy structural inequities for women and their wider families. These three themes were moderated by the relationships midwives held with women and affected the way midwives worked across the different maternity settings. CONCLUSION: Midwives carry a greater load when providing care to socio-economically deprived women. Enabling midwives to continue to provide the necessary support for women living in socio-economic deprivation is imperative and requires additional resources and funding.

Drivers of job satisfaction in midwifery-A work design approach.

BACKGROUND: Identifying common factors that influence job satisfaction for midwives working in diverse work settings is challenging. Applying a work design model developed in organisational behaviour to the midwifery context may help identify key antecedents of midwives job satisfaction. AIM: To investigate three job characteristics - decision-making autonomy, empowerment, and professional recognition as antecedents of job satisfaction in New Zealand (NZ) midwives. METHODS: Latent multiple regressions were performed on data from Lead Maternity Carer (LMC) midwives n = 327, employed midwives n = 255, and midwives working in 'mixed-roles' n = 123. FINDINGS: We found that professional recognition is positively linked to job satisfaction for midwives in all three work settings. At the same time, decision-making autonomy and empowerment were shown to influence job satisfaction for midwives working as LMCs only. DISCUSSION: Our main finding suggests that the esteem generated from being acknowledged as an expert and valuable contributor by maternity health colleagues is satisfying across all work contexts. Professional recognition encompasses the social dimension of midwifery work and influences midwives job satisfaction. Decision-making autonomy and empowerment are task and relational job characteristics that may not be similarly experienced by all midwives to noticeably influence job satisfaction. CONCLUSION: Given that job satisfaction contributes to recruitment, retention, and sustainability, our findings show that drivers of job satisfaction differ by midwifery work context. We present evidence to support tailored efforts to bolster midwives job satisfaction, especially where resources are limited.

Midwifery Job Autonomy in New Zealand: I do it all the time.

INTRODUCTION: This research aimed to identify what supports and what hinders job autonomy for midwives in New Zealand. METHODS: Registered midwives participated in an open-ended, online survey in 2019. Anonymised participants were asked to describe an incident when they felt they were using their professional judgement and/or initiative to make decisions and the resultant actions. The data was analysed thematically. FINDINGS: The participants identified that autonomy is embedded within midwifery practice in New Zealand. Self-employed midwives who provide continuity of care as Lead Maternity Carers, identified they practice autonomously 'all the time'. The relationship with women and their family, and informed decision making, motivated the midwife to advocate for the woman - regardless of the midwife's work setting. Midwifery expertise, skills, and knowledge were intrinsic to autonomy. Collegial relationships could support or hinder the midwives' autonomy while a negative hospital work culture could hinder job autonomy. DISCUSSION: Midwives identified that autonomous practice is embedded in their day to day work. It strengthens and is strengthened by their relationships with the woman/whanau and when their body of knowledge is acknowledged by their colleagues. Job autonomy was described when midwifery decisions were challenged by health professionals in hospital settings and these challenges could be viewed as obstructing job autonomy. CONCLUSION: The high job autonomy that New Zealand midwives enjoy is supported by their expertise, the women and colleagues that understand and respect their scope of practice. When their autonomy is hindered by institutional culture and professional differences provision of woman-centred care can suffer.

"Ashamed, Silent and Stuck in a System"-Applying a Structural Violence Lens to Midwives' Stories on Social Disadvantage in Pregnancy.

Historical and enduring maternal health inequities and injustices continue to grow in Aotearoa New Zealand, despite attempts to address the problem. Pregnancy increases vulnerability to poverty through a variety of mechanisms. This project qualitatively analysed an open survey response from midwives about their experiences of providing maternity care to women living with social disadvantage. We used a structural violence lens to examine the effects of social disadvantage on pregnant women. The analysis of midwives' narratives exposed three mechanisms by which women were exposed to structural violence, these included structural disempowerment, inequitable risk and the neoliberal system. Women were structurally disempowered through reduced access to agency, lack of opportunities and inadequate meeting of basic human needs. Disadvantage exacerbated risks inequitably by increasing barriers to care, exacerbating the impact of adverse life circumstances and causing chronic stress. Lastly, the neoliberal system emphasised individual responsibility that perpetuated inequities. Despite the stated aim of equitable access to health care for all in policy documents, the current system and social structure continues to perpetuate systemic disadvantage.

Can broad-spectrum multinutrients treat symptoms of antenatal depression and anxiety and improve infant development? Study protocol of a double blind, randomized, controlled trial (the 'NUTRIMUM' trial).

BACKGROUND: Untreated antenatal depression and anxiety can be associated with short and long term health impacts on the pregnant woman, her infant and the rest of the family. Alternative interventions to those currently available are needed. This clinical trial aims to investigate the efficacy and safety of a broad-spectrum multinutrient formula as a treatment for symptoms of depression and anxiety in pregnant women and to determine the impact supplementation has on the general health and development of the infant. METHODS: This randomised, controlled trial will be conducted in Canterbury, New Zealand between April 2017 and June 2022. One hundred and twenty women aged over 16 years, between 12 and 24 weeks gestation and who score ≥ 13 on the Edinburgh Postnatal Depression Scale (EPDS) will be randomly assigned to take the intervention (n = 60) or an active control formula containing iodine and riboflavin (n = 60) for 12 weeks. After 12 weeks, participants can enter an open-label phase until the birth of their infant and naturalistically followed for the first 12 months postpartum. Infants will be followed until 12 months of age. Randomisation will be computer-generated, with allocation concealment by opaque sequentially numbered envelopes. Participants and the research team including data analysts will be blinded to group assignment. The EPDS and the Clinical Global Impressions Scale of Improvement (CGI-I) will be the maternal primary outcome measures of this study and will assess the incidence of depression and anxiety and the improvement of symptomatology respectively. Generalized linear mixed effects regression models will analyse statistical differences between the multinutrient and active control group on an intent-to-treat basis. A minimum of a three-point difference in EPDS scores between the groups will identify clinical significance. Pregnancy outcomes, adverse events and side effects will also be monitored and reported. DISCUSSION: Should the multinutrient formula be shown to be beneficial for both the mother and the infant, then an alternative treatment option that may also improve the biopsychosocial development of their infants can be provided for pregnant women experiencing symptoms of depression and anxiety. TRIAL REGISTRATION: Trial ID: ACTRN12617000354381 ; prospectively registered at Australian New Zealand Clinical Trials Registry on 08/03/2017.

Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!"

OBJECTIVE: To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening. METHODS: Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach. FINDINGS: Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.

Pulse oximetry screening in a midwifery-led maternity setting with high antenatal detection of congenital heart disease.

AIM: To assess local and individual factors that should be considered in the design of a pulse oximetry screening strategy in New Zealand's midwifery-led maternity setting. METHODS: An intervention study was conducted over 2 years. Three hospitals and four primary maternity units participated in the study. Post-ductal saturation levels were measured on well infants with a gestation of ≥35 weeks. Infant activity and age (hours) at the time of the test were recorded. RESULTS: Screening was performed on 16 644 of 27 172 (61%) eligible infants. The age at which the screening algorithm was initiated varied significantly among centres. The probability of achieving a pass result (saturations ≥95%) in the context of no underlying pathology ranged from .94 for an unsettled infant screened <4 hours of age to .99 (P < .001) when the test was performed after 24 hours on a settled infant. Forty-eight (0.3%) infants failed to reach saturation targets: 37 had significant pathology of which three had cardiac disease. CONCLUSION: Screening practices were influenced by the setting in which it was undertaken. Infant activity and age at the time of testing can influence saturation levels. Screening is associated with the identification of significant non-cardiac pathology.

Feasibility study assessing equitable delivery of newborn pulse oximetry screening in New Zealand's midwifery-led maternity setting.

OBJECTIVES: The aim of this study was to conduct New Zealand-specific research to inform the design of a pulse oximetry screening strategy that ensures equity of access for the New Zealand maternity population. Equity is an important consideration as the test has the potential to benefit some populations and socioeconomic groups more than others. SETTING: New Zealand has an ethnically diverse population and a midwifery-led maternity service. One quaternary hospital and urban primary birthing unit (Region A), two regional hospitals (Region B) and three regional primary birthing units (Region C) from three Health Boards in New Zealand's North Island participated in a feasibility study of pulse oximetry screening. Home births in these regions were also included. PARTICIPANTS: There were 27 172 infants that satisfied the inclusion criteria; 16 644 (61%) were screened. The following data were collected for all well newborn infants with a gestation age ≥35 weeks: date of birth, ethnicity, type of maternity care provider, deprivation index and screening status (yes/no). The study was conducted over a 2-year period from May 2016 to April 2018. RESULTS: Screening rates improved over time. Infants born in Region B (adjusted OR=0.75; 95% CI 0.67 to 0.83) and C (adjusted OR=0.29; 95% CI 0.27 to 0.32) were less likely to receive screening compared with those born in Region A. There were significant associations between screening rates and deprivation, ethnicity and maternity care provider. Lack of human and material resources prohibited universal access to screening. CONCLUSION: A pulse oximetry screening programme that is sector-led is likely to perpetuate inequity. Screening programmes need to be designed so that resources are distributed in the way most likely to optimise health outcomes for infants born with cardiac anomalies. ETHICS APPROVAL: This study was approved by the Health and Disability Ethics Committees of New Zealand (15/NTA/168).

Adaptation and psychometric testing of the Practice Environment Scale for use with midwives.

BACKGROUND: The Practice Environment Scale (PES) has been used extensively to measure the quality of the practice environment of nurses working in a variety of work settings, and has been linked with quality of care, nurse wellbeing, job dissatisfaction and burnout. Although developed for nurses, many of the aspects addressed by the PES are also relevant to the midwifery profession, and may provide a tool to better understand midwives' decision to leave the profession. AIM: To adapt the PES for use with midwives and to assess its psychometric properties. METHODS: An online survey containing the adapted version of the PES was distributed to a sample of hospital-employed New Zealand midwives (n=600). Exploratory factor analysis was conducted to identify subscales which were compared for midwives who had, versus had not considered, leaving the midwifery profession. FINDINGS: Four subscales were identified, showing good internal consistency reliability (Quality of Management, Midwife-Doctor Relations, Resource Adequacy and Opportunities for Development). The lowest mean score was recorded for Resource Adequacy (M=2.38). All subscales of the adapted 20-item PES:Midwives were significant predictors of the decision to leave the profession (p<.001) with odds ratios above 2.0. The strongest predictor was Quality of Management (OR=2.6). CONCLUSION: The PES:Midwives was successfully adapted for use with midwives and provides a psychometrically sound tool for research to identify factors associated with the wellbeing, job satisfaction and risk of attrition amongst hospital employed midwives. The PES:Midwives also provides a means of comparing the practice environment across different models of care and employing organizations.

Increased BMI during pregnancy: how do midwife lead maternity carers respond?

AIM: To determine the knowledge base of midwife lead maternity carers (LMCs) and explore their adjustments in practice for obese women. MATERIALS & METHODS: A nationwide cohort study of LMC midwives in New Zealand concerning obesity in pregnancy using an electronic survey. RESULTS: A total of 428 LMCs responded. Most respondents were aware of the risks of obesity during pregnancy. Midwives felt it was important to provide customized care. Various barriers to accessing support for obese women within the health system were identified. Discussing weight and obesity was acknowledged as a sensitive issue for both the woman and the midwife. CONCLUSION: This study highlights the need to improve access to and availability of supportive maternity services and resources for pregnant women with increased BMI.

Supporting New Zealand graduate midwives to stay in the profession: An evaluation of the Midwifery First Year of Practice programme.

BACKGROUND: the transition from undergraduate midwifery student to working as a confident midwife can be challenging for many newly qualified midwives. Supporting a smooth transition may have a positive impact on the confidence and retention of the new graduates within the workforce. In New Zealand the Midwifery First Year of Practice programme (MFYP) was introduced in 2007 as a structured programme of support for new graduate midwives for the whole of their first year of practice. The main components of the programme include support during clinical practice, provision of a funded mentor midwife chosen by the new graduate midwife, financial assistance for education and a requirement to undertake a quality assessment and reflection process at the end of the first year. AIM: the aim of this study was to explore the retention of new graduates in midwifery practice following participation in the Midwifery First Year of Practice programme. METHOD: data was obtained from the register of MFYP participants between the years 2007 and 2010. This data was cross referenced with the Midwifery Council of New Zealand register and workforce data for 2012. FINDINGS: between the years 2007 and 2010 there were 441 midwives who graduated from a midwifery pre-registration education programme in New Zealand. Of these 415 participated in the MFYP programme. The majority were of New Zealand European ethnicity with 10% identifying as Maori. The mean age of participants reduced from 36.4 (SD 7.3) in 2007 to 33.4 (SD 8.1) in 2010. The overall retention rate for new graduate midwives who had participated in the MFYP programme was 86.3%, with 358 midwives still practising in 2012. CONCLUSION: there is good retention of new graduate midwives within New Zealand and the MFYP programme would appear to support retention.

The emotional journey of labour-women's perspectives of the experience of labour moving towards birth.

BACKGROUND: there has been minimal exploration of women's emotional flow during labour and towards birth. This research aimed to capture woman's remembered experiences of this process. METHOD: a critical feminist standpoint methodology guided this research which used in depth interviews to explore the perspectives of 18 women who had experienced a spontaneous labour and birth. These women all had continuity of care from a known midwife FINDINGS: women described labour and birth in terms of their emotions. These emotions flowed from excitement at the beginning, to calm as they waited for the labour to strengthen. This waiting time was variable in length and the women were often able to continue with many aspects of normal life. As the labour intensified women described moving into a 'zone' of timelessness and spacelessness; a time of letting go of control. The external world was shut out. Some women described feeling overwhelmed as the birth approached, others felt intensely tired. During the birth the women returned to a state of alertness. Some described shock or disbelief. They were surprised at how effectively their body had worked and taken them through labour. CONCLUSION AND IMPLICATION FOR PRACTICE: women described labour as defined by their emotions. The feelings described were linear and consistent and may be an indication of normal labour and birth physiology. These descriptions may be helpful when supporting women during labour and birth.

Outcomes of physiological and active third stage labour care amongst women in New Zealand.

BACKGROUND: during the third stage of labour there are two approaches for care provision - active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units). METHODS: retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby. FINDINGS: the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441-3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management - 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6). CONCLUSIONS: the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.

Women's perspectives of the stages and phases of labour.

BACKGROUND: within childbirth there is a common and widely known explanation of labour and birth which describes and defines the birth process as stages and phases. The aim of this research was to determine whether the discourse of labour as stages and phases resonated with women who had experienced spontaneous labour and birth. METHOD: a critical feminist standpoint methodology was used to explore the perspectives of 18 New Zealand women through in-depth, one to one, interviews. FINDINGS: the participants did not talk about their labour as occurring in stages or phases and often considered this description to be an abstract concept. The current descriptions of labour onset and progression did not appear to resonate with these women or provide sufficient clarity for them to understand how far they had progressed in their labour. For women who had previously laboured there was the ability to make comparisons with their previous experiences and therefore experiential knowledge was privileged over other forms of knowledge. Despite this the discourse of measurement of cervical dilatation was dominant and considered as an authoritative means of determining labour and labour progress. CONCLUSION AND IMPLICATION FOR PRACTICE: women considered labour to be a continuous process. If women are to be able to make sense of their experience of labour, the maternity sector needs to explore and determine descriptions of labour which resonate more fully with the woman's experience of labour and birth.

Irish and New Zealand midwives' expertise in expectant management of the third stage of labour: the 'MEET' study.

OBJECTIVE: to explore the views of expert midwives in Ireland and New Zealand of the skills they employ in expectant management of the third stage of labour (EMTSL). DESIGN: university ethical approval was granted for a qualitative descriptive study in 2010. Recorded, semi-structured interviews were undertaken. Constant comparative analysis was used. SETTING: community birth settings in Ireland and New Zealand. PARTICIPANTS: 27 consenting midwives who used EMTSL in at least 30% of births, with PPH rates less than 4%. FINDINGS: the majority of respondents believed the third stage was a special time of parent-baby discovery and 'watchful waiting', with no intervention necessary. Great importance was placed on women's feelings, behaviour and a calm environment. Skin-to-skin contact, breast feeding, not clamping the cord, upright positions and maternal effort, sometimes assisted by gentle cord-traction were also used. KEY CONCLUSIONS: some components of EMTSL identified by these expert midwives are not recorded in text-books, but are based on experience and expertise. These elements of EMTSL add to midwifery knowledge and provide a basis for further discussion on how normal physiology can be supported during the third stage. IMPLICATIONS FOR PRACTICE: use of these elements is recommended for women who request EMTSL, and for those in countries without ready access to uterotonics.

Planned place of birth in New Zealand: does it affect mode of birth and intervention rates among low-risk women?

BACKGROUND: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low-risk women planning to give birth in these settings under the care of midwives. METHODS: Data for a cohort of low-risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. RESULTS: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66-5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05-1.87; RR: 1.78, 95% CI: 1.31-2.42) than women planning to give birth in a primary unit. CONCLUSIONS: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

Phthalazinones 2: Optimisation and synthesis of novel potent inhibitors of poly(ADP-ribose)polymerase.

We have previously described the discovery of poly(ADP-ribose)polymerase-1 (PARP-1) inhibitors based on a phthalazinone scaffold. Subsequent optimisation of inhibitory activity, metabolic stability and pharmacokinetic parameters has led to a novel series of meta-substituted 4-benzyl-2H-phthalazin-1-one PARP-1 inhibitors which retain low nM cellular activity and show good stability in vivo and efficacy in cell based models.