Getting kicked off the program: Women's experiences of antenatal exclusion from publicly-funded homebirth in Australia.

PROBLEM: Eligibility criteria for publicly-funded homebirth models are strict and, as such, many women who initially plan a homebirth later become excluded. BACKGROUND: Fifteen publicly-funded homebirth programs are operating in Australia, offering eligible women the opportunity to give birth at home at no cost, with the care of a hospital-employed midwife. AIM: To explore the experiences of women who planned a publicly-funded homebirth and were later excluded due to pregnancy complications or risk factors. METHODS: A qualitative descriptive approach was taken. Recruitment was via social media sites specifically related to homebirth in Australia. Data collection involved semi-structured telephone interviews. Transcripts were thematically analysed. FINDINGS: Thirteen women participated. They were anxious about 'Jumping through hoops' to maintain their low-risk status. After being 'Kicked off the program', women carefully 'negotiated the system' in order to get the birth they wanted in hospital. Some women felt bullied and coerced into complying with hospital protocols that did not account for their individual needs. Maintaining the midwife-woman relationship was a protective factor, decreasing negative experiences. DISCUSSION: Women plan a homebirth to avoid the medicalised hospital environment and to gain access to continuity of midwifery care. To provide maternity care that is acceptable to women, hospital institutions need to design services that enable continuity of the midwife-woman relationship and assess risk on an individual basis. CONCLUSION: Exclusion from publicly-funded homebirth has the potential to negatively impact women who may feel a sense of loss, uncertainty or emotional distress related to their planned place of birth.

Babies born with ambiguous genitalia: Developing an educational resource for Australian midwives.

PROBLEM AND BACKGROUND: The birth of a baby with ambiguous genitalia is rare and usually unexpected. Parents often receive inconsistent language from health-professionals after the birth. Initial interaction with the birth team has long-term consequences for families with babies born with ambiguous genitalia. AIM: Understand the current practices on the day of birth and explore knowledge gaps for midwives regarding babies born with ambiguous genitalia. Develop educational content that can enable midwives to respond appropriately when the sex of a baby is unclear. METHODS: This study included two phases, utilising qualitative descriptive research design with semi-structured interviews to understand the experiences of midwives caring for babies with ambiguous genitalia and their families. The findings informed the development a midwifery educational resource using these qualitative findings. FINDINGS: Our analysis of 14 interviews with Australian midwives identified that they had no formal education to support families with a baby with ambiguous genitalia. Emotional support, advocacy and medical information translation were areas midwives perceived as essential skills to support these families. DISCUSSION: Midwives provide a unique role in parental birth experiences. Themes that arose emphasised their psychosocial support role but lacked formal education and guidance on this topic. Midwives had learnt from the media about babies born with ambiguous genitalia and wanted evidence-based education to support parents. Midwife education focusing on both psychosocial and clinical care for parents and their baby with ambiguous genitalia is crucial. CONCLUSION: Midwives can play a pivotal role in supporting parents with a baby with ambiguous genitalia. Themes from this qualitative study informed the development of a midwifery education digital resource.

Perinatal mental healthcare: Developing skills in midwifery students.

Midwives have a pivotal role in screening for risk factors for mental illness and psychosocial vulnerabilities in women during the perinatal period. They also have a key responsibility to provide women with the appropriate resources to support their mental wellbeing. Midwives can lack confidence and/or feelings of competence regarding these skills. Care of women in the context of their perinatal mental health is a core midwifery skill that deserves practical learning during pre-registration education, just as the more 'hands on' skills such as abdominal palpation, labour and birth support or newborn examination. However, there is limited opportunity for students to gain clinical placement experiences that are specific to perinatal mental health (PMH). This discussion paper describes an innovative teaching and learning project that aimed to improve confidence in students' ability to conduct screening, support, and referral of women experiencing mental ill health. The project involved the development of an Objective Structured Clinical Examination (OSCE) and audio visual resources to support learning and teaching and clinical placement. Feedback was collected to inform the refinement of the first OSCE, and to assist in the design of the audio visual resources that are now displayed publicly on the Australian College of Midwives website at https://www.midwives.org.au/Web/Web/Professional-Development/Resources.aspx?hkey=12c2360e-d8b9-4286-8d0a-50aeaeca9702.

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review.

BACKGROUND: All women require access to quality maternity care. Continuity of midwifery care can enhance women's experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities. AIM: To explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia. METHODS: This integrative review used Whittemore and Knafl's approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools. FINDINGS: Fourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: 'Contributing to safe processes and outcomes', 'Building relational trust', and 'Collaborating and communicating'. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women. DISCUSSION: The nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice. CONCLUSION: Despite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.

Wanting to be 'with woman', not with machine: Midwives' experiences of caring for women being continuously monitored in labour.

PROBLEM: Some continuous electronic fetal monitoring (CEFM) devices restrict women's bodily autonomy by limiting their mobility in labour and birth. BACKGROUND: Little is known about how midwives perceive the impact of CEFM technologies on their practice. AIM: This paper explores the way different fetal monitoring technologies influence the work of midwives. METHODS: Wireless and beltless 'non-invasive fetal electrocardiogram' (NIFECG) was trialled on 110 labouring women in an Australian maternity hospital. A focus group pertaining to midwives' experiences of using CTG was conducted prior to the trial. After the trial, midwives were asked about their experiences of using NIFECG. All data were analysed using thematic analysis. FINDINGS: Midwives felt that wired CTG creates barriers to physiological processes. Whilst wireless CTG enables greater freedom of movement for women, it requires constant 'fiddling' from midwives, drawing their attention away from the woman. Midwives felt the NIFECG better enabled them to be 'with woman'. DISCUSSION: Midwives play a pivotal role in mediating the influence of CEFM on women's experiences in labour. Exploring the way in which different forms of CEFM impact on midwives' practice may assist us to better understand how to prioritise the woman in order to facilitate safe and satisfying birth experiences. CONCLUSION: The presence of CEFM technology in the birth space impacts midwives' ways of working and their capacity to be woman-centred. Current CTG technology may impede midwives' capacity to be 'with woman'. Compared to the CTG, the NIFECG has the potential to enable midwives to provide more woman-centred care for those experiencing complex pregnancies.

Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework.

PROBLEM: Midwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow. BACKGROUND: It is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services. AIM: We aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings. METHODS: Data were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework. FINDINGS: Good quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes. DISCUSSION: Midwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework. CONCLUSION: The QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care.

Development and validation of the Australian Midwifery Standards Assessment Tool (AMSAT) to the Australian Midwife Standards for Practice 2018.

BACKGROUND: The Australian Midwifery Standards Assessment Tool (AMSAT) was developed against the Competency Standards for the Midwife in 2017 to enable consistent assessment of midwifery student performance in practice-based settings. The AMSAT requires revision and re-validation as the competency standards have now been superseded by the Midwife Standards for Practice 2018. OBJECTIVE: This research revised and validated the AMSAT to assess performance of midwifery students against the Midwife Standards for Practice 2018 and assessed its sensitivity. DESIGN: A mixed-methods approach was used in a two-phase process. Phase one involved the re-wording of the AMSAT and behavioural cue statements in an iterative participatory process with midwifery academics, assessors and students. The tool was field-tested in different assessment environments in phase two. Completed assessment forms were statistically analyzed, whilst assessor surveys were analysed using descriptive statistics and qualitative content analysis. FINDINGS: Analysis of AMSAT (n=255) indicates the tool as: internally reliable (Cronbach alpha>.9); valid (eigenvalue of 16.6 explaining 67% of variance); and sensitive (score analysis indicating increased levels of proficiency with progressive student experience). Analysis of surveys (n=108) found acceptance of the tool for the purpose of summative and formative assessment, and in the provision of feedback to midwifery students on their performance. CONCLUSION: This study demonstrates that the re-developed AMSAT is a valid, reliable and acceptable tool to assess midwifery students' performance against the Australian Midwife Standards for Practice This user-friendly tool can be used to standardize midwifery student assessment in Australia and enable continued benchmarking across education programs.

Developing nursing and midwifery students' capacity for coping with bullying and aggression in clinical settings: Students' evaluation of a learning resource.

An innovative blended learning resource for undergraduate nursing and midwifery students was developed in a large urban Australian university, following a number of concerning reports by students on their experiences of bullying and aggression in clinical settings. The blended learning resource included interactive online learning modules, comprising film clips of realistic clinical scenarios, related readings, and reflective questions, followed by in-class role-play practice of effective responses to bullying and aggression. On completion of the blended learning resource 210 participants completed an anonymous survey (65.2% response rate). Qualitative data was collected and a thematic analysis of the participants' responses revealed the following themes: 'Engaging with the blended learning resource'; 'Responding to bullying' and 'Responding to aggression'. We assert that developing nursing and midwifery students' capacity to effectively respond to aggression and bullying, using a self-paced blended learning resource, provides a solution to managing some of the demands of the clinical setting. The blended learning resource, whereby nursing and midwifery students were introduced to realistic portrayals of bullying and aggression in clinical settings, developed their repertoire of effective responding and coping skills for use in their professional practice.

Peer to peer mentoring: Outcomes of third-year midwifery students mentoring first-year students.

PROBLEM: Undergraduate midwifery students commonly experience anxiety in relation to their first clinical placement. BACKGROUND: A peer mentoring program for midwifery students was implemented in an urban Australian university. The participants were first-year mentee and third-year mentor students studying a three-year Bachelor degree in midwifery. The program offered peer support to first-year midwifery students who had little or no previous exposure to hospital clinical settings. Mentors received the opportunity to develop mentoring and leadership skills. AIM: The aim was to explore the benefits, if any, of a peer mentoring program for midwifery students. METHODS: The peer mentoring program was implemented in 2012. Sixty-three peer mentors and 170 mentees participated over three academic years. Surveys were distributed at the end of each academic year. Quantitative survey data were analysed descriptively and qualitative survey data were analysed thematically using NVivo 10 software. FINDINGS: Over 80% of mentors and mentees felt that the program helped mentees adjust to their midwifery clinical placement. At least 75% of mentors benefited, in developing their communication, mentoring and leadership skills. Three themes emerged from the qualitative data, including 'Receiving start-up advice'; 'Knowing she was there' and 'Wanting more face to face time'. DISCUSSION: There is a paucity of literature on midwifery student peer mentoring. The findings of this program demonstrate the value of peer support for mentees and adds knowledge about the mentor experience for undergraduate midwifery students. CONCLUSION: The peer mentor program was of benefit to the majority of midwifery students.

Simulation workshops with first year midwifery students.

Simulated teaching methods enable a safe learning environment that are structured, constructive and reflective. We prepared a 2-day simulation project to help prepare students for their first clinical practice. A quasi-experimental pre-test - post-test design was conducted. Qualitative data from the open-ended survey questions were analysed using content analysis. Confidence intervals and p-values were calculated to demonstrate the changes in participants' levels of understanding/ability or confidence in clinical midwifery skills included in the simulation. 71 midwifery students participated. Students rated their understanding, confidence, and abilities as higher after the simulation workshop, and higher still after their clinical experience. There were five main themes arising from the qualitative data: having a learning experience, building confidence, identifying learning needs, developing communication skills and putting skills into practise. First year midwifery students felt well prepared for the clinical workplace following the simulation workshops. Self-rated understanding, confidence and abilities in clinical midwifery skills were significantly higher following consolidation during clinical placement. Longitudinal studies on the relationship between simulation activities and student's overall clinical experience, their intentions to remain in midwifery, and facility feedback, would be desirable.