Putting co-creation into practice: lessons learned from developing a midwife-led quality improvement intervention.

BACKGROUND: Integrating evidence-based midwifery practices improves healthcare quality for women and newborns, but an evidence-to-practice gap exists. Co-created quality improvement initiatives led by midwives could bridge this gap, prevent resource waste and ensure intervention relevance. However, how to co-create a midwife-led quality improvement intervention has not been scientifically explored. OBJECTIVE: The objective of this study is to describe the co-creation process and explore the needs and determinants of a midwife-led quality improvement targeting evidence-based midwifery practices. METHODS: A qualitative deductive approach using the Consolidated Framework for Advancing Implementation Science was employed. An analysis matrix based on the framework was developed, and the data were coded according to categories. Data were gathered from interviews, focus group discussions, observations and workshops. New mothers and birth companions (n = 19) were included through convenience sampling. Midwives (n = 26), professional association representatives, educators, policymakers, managers, and doctors (n = 7) were purposely sampled. RESULTS: The co-creation process of the midwife-led Quality Improvement intervention took place in four stages. Firstly, core elements of the intervention were established, featuring a group of midwife champions leading a quality improvement initiative using a train-the-trainers approach. Secondly, the intervention needs, context and determinants were explored, which showed knowledge and skills gaps, a lack of shared goals among staff, and limited resources. However, there was clear relevance, compatibility, and mission alignment for a midwife-led quality improvement at all levels. Thirdly, during co-creation workshops with new mothers and companions, the consensus was to prioritise improved intrapartum support, while workshops with midwives identified enhancing the use of birth positions and perineal protection as key focus areas for the forthcoming Quality Improvement intervention. Lastly, the findings guided intervention strategies, including peer-assisted learning, using existing structures, developing educational material, and building stakeholder relationships. CONCLUSIONS: This study provides a practical example of a co-creation process for a midwife-led quality improvement intervention, which can be relevant in different maternity care settings.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya.

BACKGROUND: Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability. METHODS: We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD). RESULTS: At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD. CONCLUSION: Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda.

OBJECTIVE: To identify and examine barriers to midwife-led care in Eastern Africa and how these barriers can be reduced DESIGN: A qualitative inductive study with online focus group discussions and semi-structured interviews using content analysis SETTING: The study examines midwife-led care in Ethiopia, Malawi, Kenya, Somalia, and Uganda -five African countries with an unmet need for midwives and a need to improve maternal and neonatal health outcomes. PARTICIPANTS: Twenty-five participants with a health care profession background and current position as a maternal and child health leader from one of the five study countries. FINDINGS: The findings demonstrate barriers to midwife-led care connected to organisational structures, traditional hierarchies, gender disparities, and inadequate leadership. Societal and gendered norms, organisational traditions, and differences in power and authority between professions are some factors explaining why the barriers persist. A focus on intra- and multisectoral collaborations, the inclusion of midwife leaders, and providing midwives with role models to leverage their empowerment are examples of how to reduce the barriers. KEY CONCLUSIONS: This study provides new knowledge on midwife-led care from the perspectives of health leaders in five African countries. Transforming outdated structures to ensure midwives are empowered to deliver midwife-led care at all healthcare system levels is crucial to moving forward. IMPLICATIONS FOR PRACTISE: This knowledge is important as enhancing the midwife-led care provision is associated with substantially improved maternal and neonatal health outcomes, higher satisfaction of care, and enhanced utilisation of health system resources. Nevertheless, the model of care is not adequately integrated into the five countries' health systems. Future studies are warranted to further explore how reducing barriers to midwife-led care can be adapted at a broader level.

Satisfaction with life and associated factors among elderly people living in two cities in northwest Ethiopia: a community-based cross-sectional study.

OBJECTIVE: This study aimed to determine the level of life satisfaction and identify associated factors among elderly people living in two cities in northwest Ethiopia. DESIGN: Community-based cross-sectional study. SETTING: Two cities in northwest Ethiopia (Gondar and Bahir Dar). PARTICIPANTS: 816 elderly people age 60 years and above living in Gondar and Bahir Dar, northwest Ethiopia. Systematic random sampling was used to select study participants. MAIN OUTCOME MEASURE: Level of life satisfaction. Considering the mean and SD, three levels of satisfaction appeared to suffice as the basis for analysis and discussion: 23.5-34.4 dissatisfied, 34.5-56.5 averagely satisfied and 56.6-67.5 satisfied. Multivariable ordinal regression analysis was done to control the confounders. Since the outcome variable has an ordinal category, ordinal regression analysis is appropriate. A p≤0.05 and AOR (adjusted OR) with a 95% CI were considered to determine the statistically significant variables and strength of the association. RESULTS: The mean age of the respondents was 68.2 years with an SD±7.2. The level of life satisfaction was: dissatisfied 17.2%, moderately satisfied 63.8% and well satisfied 19.0%. Overall, 45.8% (95% CI 42.2% to 49.2%) of the participants had a score equal to or above the mean. Regarding associated factors; retired current occupation (AOR=2.23, 95% CI 1.09 to 4.55), good self-rated health status (AOR=2.54, 95% CI 1.29 to 4.99), having no chronic disease (AOR=1.48, 95% CI 1.03 to 2.11), somewhat-good (AOR=2.15, 95% CI 1.12 to 4.13) and good (AOR=4.51, 95% CI 2.40 to 8.45) self-perception on ageing life, moderate functional impairment on daily living activities (AOR=5.43, 95% CI 1.81 to 16.24), high sense of coherence (AOR=3.80, 95% CI 2.04 to 7.08), house rent as a source of finance (AOR=2.60, 95% CI 1.49 to 4.52) and high perceived social support (AOR=2.13, 95% CI 1.44 to 3.16) had statistically significant association with the life satisfaction. CONCLUSION: The life satisfaction level in our study group was lower than in some more highly developed countries. To improve the level of life satisfaction in Ethiopia, a holistic programme of nursing care for elderly people, particularly as concerns about their health and psychosocial conditions is crucial in both community and clinical settings.

The MIDWIZE conceptual framework: a midwife-led care model that fits the Swedish health care system might after contextualization, fit others.

OBJECTIVE: Familiarity with the unique tradition and experience of Swedish midwives during the more than 300 years in which midwife-led care has contributed to one of the lowest maternal and neonatal mortality and morbidity ratio in the world might encourage professionals in other countries to follow the Swedish example. The framework described below, reflecting the midwife's role in the Swedish health care system, might, after implementation, strengthen maternal and neonatal outcomes if contextualized to other settings. RESULTS: Using a four-step procedure we identified our topic, made a literature review, identified the key components and their internal relationship, and finally developed the MIDWIZE conceptual framework. In this framework, the midwives in collaboration with obstetricians, provide evidence-based care with continuous quality improvements during the whole reproductive life cycle. Teamwork including specialists for referral and a responsive, relational, trust-based practice is the foundation for provision of midwife-led care for healthy women with a normal pregnancy. The well-educated midwife, of high academic standard, promoting gender equality and equity is the hub in the team and the primary care provider.

Development of a tool to analyse what resources are needed to implement a midwife-led care framework- the MIDWIZE conceptual framework.

BACKGROUND: A midwife led care project targeting to decide what to do to achieve the SDG 2030 in maternal and child health, made a project team develop a tool to analyse what health care systems need, to adopt the MIDWIZE Conceptual Framework. The MIDWIZE Conceptual Framework wish to introduce the comprehensive midwifery-managed care provided women in Sweden to other countries, regions, and units where the framework is not fully applied. METHODS: In order to determine what resource needs would have to be met to improve midwife led care, a tool was developed using Delphi study technique. RESULTS: Using Delphi study technique together with on-site visits to two Sub-Saharan African countries, members of a project team went to Ethiopia and Uganda, where they visited governments, clinical or educational institutions and together with African leaders developed availability and efficiency of a tool to determine resource needs. CONCLUSION: If at some future time, a single country, region or unit, might want to use the tool for quality improvement purpose of midwife led care, then the tool might aid in taking the first step to determine what resources might be required and what changes might be recommended as concerns policy at the clinical or educational institution level that are part of already existing health care structures.

The midwife's role in achieving the Sustainable Development Goals: protect and invest together - the Swedish example.

'The midwife's role in achieving the Sustainable Development Goals: Protect and Invest Together' is a report providing the reader the opportunity for understanding and appreciating the history of midwifery in Sweden and the interlinked nature of the United Nation's SDGs supporting health and wellbeing of women and children. To realise the opportunity to have a country with well-educated midwives of high academic standard, and, at the same time, promoting gender equality and equity we need to protect and invest together in midwives. This paper provides the foundation for a revitalised discussion on midwives' role for women and child health in the 21st century. The full Swedish Midwifery report was published in October 2021.

Midwife-led continuity of care increases women's satisfaction with antenatal, intrapartum, and postpartum care: North Shoa, Amhara regional state, Ethiopia: A quasi-experimental study.

BACKGROUND: The provision of midwife-led continuity of care (MLCC) is effective in high-resource settings in improving maternal satisfaction. This study aimed to evaluate the effect of MLCC on women's satisfaction with care in a low-income/resource setting. METHOD: A study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals in the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low-risk women were allocated to one of two groups; the MLCC (intervention group) that received all antenatal, intrapartum, and immediate postnatal care from a primary midwife or backup midwife) (n = 589) and the shared model of care (SMC) group that received care following established practice in Ethiopia, care from different staff members at different times) (n = 589). Data for this paper were collected using face-to-face interviews at the women's home at the end of the postpartum period. The study's outcome was the mean sum-score of satisfaction with care through the antenatal, intrapartum, and postnatal period continuum, where mean sum-scores range from 1 (lowest) to 5 (highest). FINDINGS: Compared with SMC, MLCC was associated with statistically significantly higher satisfaction with all continuity of care (4.07 vs. 2.79 adjusted mean difference 1.27, 95% CI 1.18-1.35; p < 0.001), during antenatal care (4.14 vs. 2.81 adjusted mean difference 1.33 (95% CI 1.22-1.52), intrapartum care (3.83 vs. 2.71 adjusted mean difference 1.06 (95% CI 0.88-1.23) and postnatal care (5.46 vs. 3.71 adjusted mean difference 1.75 (95% CI 1.54-1.94)). CONCLUSION: MLCC increased women's satisfaction with maternity care for women at low risk of medical complications. These findings confirm that the MLCC model will be applicable in the Ethiopian health care system with similar settings.

Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone, Amhara regional state, Ethiopia: A quasi-experimental study.

BACKGROUND: In a low-resource setting, information on the effect of midwife-led continuity of care (MLCC) is limited. Therefore, this study aimed to determine the effect of MLCC on maternal and neonatal health outcomes in the Ethiopian context. METHOD: A study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals of the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low risk women were allocated to one of two groups; the midwife-led continuity of care (MLCC or intervention group) (received all antenatal, labour, birth, and immediate postnatal care from a single midwife or backup midwife) (n = 589) and the Shared model of care (SMC or comparison group) (received care from different staff members at different times) (n = 589). The two outcomes studied were Spontaneous vaginal birth and preterm birth. Outcome variables were compared using multivariate generalized linear models (GLMs) and reported using adjusted risk ratios (aRR) with 95% confidence intervals. FINDINGS: Women in MLCC were, in comparison with women in the SMC group more likely to have spontaneous vaginal birth (aRR of 1.198 (95% CI 1.101-1.303)). Neonates of women in MLCC were in comparison with those in SMC less likely to be preterm (aRR of 0.394; 95% CI (0.227-0.683)). CONCLUSION: In this study, use of the MLCC model improved maternal and neonatal health outcomes. To scale up and further investigate the effect and feasibility of this model in a low resource setting could be of considerable importance in Ethiopia and other Sub-Saharan Africa countries.

Health care providers' perceptions and experiences related to Midwife-led continuity of care-A qualitative study.

BACKGROUND: Though Midwife-led care remains a key to improving the health status of pregnant mothers, in Ethiopia, maternity care has traditionally been based on a model in which responsibility for care is shared by hospital-based midwives, nurses, general practitioners, and obstetricians. This type of care has been seen as representing a fragmented approach. OBJECTIVE: The aim of this study was to explore health care providers' perceptions and experiences related to Midwife-led continuity of care at primary hospitals in the north Shoa zone Ethiopia. METHODS: A qualitative approach was selected as the methodology for this study. Data were collected from 25 midwives and 8 integrated emergency surgical officers (IESO) and medical doctors working in maternal health care units in four primary hospitals in the north Shoa zone, Amhara Regional State. Four focus group discussions and eight individual interviews were conducted. The facilitator utilized a set of open-ended questions for the focus group discussion. Semi-structured interview questions were used for the interviews and thematic data analysis was done. FINDING: The main theme extracted was "Midwives welcome consideration of a Midwife-led model that would provide greater continuity of care, but they expressed concerns about organisation and workload". The midwives said that they would welcome working with the midwife-led care model, as they believed using it could lead to improving the quality of maternal health care, provide greater continuity, and improve coverage, birth outcomes, and maternal satisfaction. The midwives could become more autonomous and be able to take more responsibility for maternity care. The group of 25 midwives and the group of 8 IESO and medical doctors perceived that working procedures and changes in the organization of care in the health facility would have to be studied carefully before any changes can be considered. CONCLUSION: In this study, we found that replacing the existing system of maternal care with a Midwife-led model would require careful analysis of how this model of care might be implemented in Ethiopia. Further investigation will be of great importance in providing insights that will help in developing a final model.

Half-time evaluation of a new 4-year Ph.D. program in nursing and midwifery at the University of Gondar, Ethiopia.

A new four-year Ph.D. programme in nursing and midwifery, the first of its kind in Ethiopia, was started in 2018/2019 at the University of Gondar when eight doctoral students in nursing and midwifery entered the program. We who have been involved see this as an appropriate time to evaluate what has been accomplished to date and to look toward future possibilities. Our aim in carrying out such an evaluation and presenting our findings is in part to determine if similar programs might be developed in other similar settings and in part to learn what modifications to the present program might be considered. The key elements of a questionnaire survey with closed and open response alternatives were based on the content, structure and learning outcomes of the home university Ph.D. programme as described in the curriculum. The questionnaire responses captured changes that would be needed to maintain a fully satisfactory programme that blends onsite instruction and online access to faculty resulting in a twenty-first century blended Ph.D. programme. Improved dialogue between the home university faculty and the external supervisors is needed. The programme can provide a career pathway that midwifery and nursing educators can follow in their own country rather than having to leave to study in another country. The findings provide insight into the feasibility of extending similar Ph.D. programmes to other parts of East Africa and with the SDG 5 in mind with an increased focus on women leadership. The justification for this initiative is to meet the need for more nursing and midwifery faculty who can provide quality midwifery and nursing education in East African countries. Retention of these professionals will help to deal with the shortage of healthcare personnel and will provide better care for the general population.

Developing a midwifery service task list for Chinese midwives in the task-shifting context: a Delphi study.

OBJECTIVE: To develop and validate a midwifery-led task list in the task-shifting context. DESIGN: An extensive literature review followed by a two-iterative Delphi survey. SETTING: Twenty university hospitals, three non-university hospitals and four university colleges from nine provincial regions of China. PARTICIPANTS: Purposive non-probability sampling of a national panel of experts in maternal healthcare, obstetrics, nursing and midwifery. Experts in the panel were asked to rate each midwifery service item regarding importance, feasibility and advancement on a 5-point scale, in order to determine those best suited for midwifery-led practice in China. RESULTS: Two rounds of Delphi surveys were completed before consensus was achieved, with effective response rate ranging from 96.4% (27/28) to 100% (27/27), indicating a high positive coefficient of the experts. The authority coefficient of experts was 0.882, indicating the high reliability of this study. The Kendall harmony coefficient (W) in the two rounds of consultations was 0.196 (p<0.001) and 0.324 (p<0.001), respectively. A detailed, three-level midwifery-led task list was developed, including 3 domains of midwifery practice (first-level indicators), 13 types of task (second-level indicators) and 58 midwifery service items (third-level indicators). The 3 domains of midwifery practice involved the appropriate scope of practice for Chinese midwives, including antenatal care, intrapartum care and postnatal care. The 58 service items embraced core components of caring task in the Chinese midwifery profession. CONCLUSION: This study outlines the first midwifery-led task list that defines clearly the Chinese midwives' scope of practice. It will provide a foundational framework for future midwifery practice in China and abroad, and can be used to inform the design of midwifery-led task shifting interventions in various maternity settings.

African midwifery students' self-assessed confidence in postnatal and newborn care: A multi-country survey.

BACKGROUND: Majority of maternal and new-born deaths occur within 28 hours and one week after birth. These can be prevented by well-educated midwives. Confidence in postnatal and newborn care skills depend on the quality of midwifery education. OBJECTIVE: To assess confidence and its associated factors for basic postnatal and new-born care skills of final year midwifery students , from seven African countries. METHODS: A multi-country cross-sectional study where final year midwifery students answered a questionnaire consisting of basic skills of postnatal and newborn care listed by the International Confederation of Midwives. The postnatal care area had 16 and newborn care area had 19 skill statements. The 16 skills of postnatal care were grouped into three domains through principle component analysis (PCA); Basic postnatal care; postnatal complications and educating parents and documentation. The 19 skills under the newborn care area were grouped into three domains; Basic care and care for newborn complications; Support parents for newborn care; and Care for newborns of HIV positive mothers and documentation. RESULTS: In total 1408 midwifery students from seven Sub-Saharan countries participated in the study namely; Kenya, Malawi, Tanzania, Uganda, Zambia, Zimbabwe, and Somaliland Overall high confidence for all domains under Post Natal Care ranged from 30%-50% and for Newborn care from 39-55%. High confidence for postnatal skills was not found to be associated with any background variables (Age, sex, type and level of educational programme). High confidence for newborn care was associated with being female students, those aged 26-35 years, students from the direct entry programmes and those enrolled in diploma programmes. CONCLUSIONS: Almost half of the study participants expressed lack of confidence for skills under postnatal and newborn care. No association was found between high confidence for domains of postnatal care and background variables. High confidence was associated with being a female, between 26-35 years of age, from direct entry or diploma programmes for newborn care area. The results of the study indicate gaps in midwifery education. Countries could use the ICM list of competencies to develop country specific standards for midwifery education. However, actual competence remains to be measured.

The community-based bilingual doula - A new actor filling gaps in labour care for migrant women. Findings from a qualitative study of midwives' and obstetricians' experiences.

OBJECTIVES: To explore midwives' and obstetricians' views about community-based bilingual doula (CBD) support during migrant women's labour and birth and their experiences of collaborating with CBDs. STUDY DESIGN: A qualitative study with semi-structured individual interviews with 7 midwives and 4 obstetricians holding clinical positions in labour care in Stockholm, Sweden, who all had experiences of working with a CBD. Data analysis followed the framework of thematic analysis. RESULTS: The overarching theme was A new actor filling gaps in labour care - With appropriate boundary setting, CBDs can help improve care for migrant women. One year after the introduction of CBDs, the midwives and obstetricians had mainly positive experiences of CBDs who were considered to fill important gaps in maternity care for migrant women, being with the woman and simultaneously being part of the care team and this made providing high quality care easier. The CBDs' main contribution was to help migrant women navigate the maternity care system, to bridge language and cultural divides, and guarantee continuous labour and birth support. However, midwives and obstetricians sometimes experienced CBDs interfering with their professional assessments and decisions and the role of the CBD was somewhat unclear to them. CONCLUSIONS: Community-based bilingual doula support was viewed as improving migrant women's well-being during labour and birth and as increasing the possibilities for midwives and obstetricians to provide good and safe care, however, some ambivalence remained about the CBD's role and boundaries.

Midwives' experiences of using the Mindfetalness method when talking with pregnant women about fetal movements.

BACKGROUND: Information given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby's fetal movement pattern. AIM: We aimed to explore midwives' perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work. METHODS: A web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire. FINDINGS: The midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task. CONCLUSION: Mindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.

A decrease in cesarean sections and labor inductions among Swedish women by awareness of fetal movements with the Mindfetalness method.

BACKGROUND: Maternal perception of decreased fetal movements is commonly used to assess fetal well-being. However, there are different opinions on whether healthcare professionals should encourage maternal observation of fetal movements, as researchers claim that raising awareness increases unnecessary interventions, without improving perinatal health. We aimed to investigate whether cesarean sections and labor induction increase by raising women's awareness of fetal movements through Mindfetalness. Further, we aimed to study perinatal health after implementing Mindfetalness in maternity care. METHODS: In a cluster randomized controlled trial, 67 maternity clinics were allocated to Mindfetalness or routine care. In the Mindfetalness group, midwives distributed a leaflet telling the women to focus on the character, strength and frequency of the fetal movements without counting each movement. The instruction was to do so for 15 min daily when the fetus was awake, from gestational week 28 until birth. In this sub-group analysis, we targeted women born in Sweden giving birth from 32 weeks' gestation. We applied the intention-to-treat principle. RESULTS: The Mindfetalness group included 13,029 women and the Routine-care group 13,456 women. Women randomized to Mindfetalness had less cesarean sections (18.4% vs. 20.0%, RR 0.92, CI 0.87-0.97) and labor inductions (19.2% vs. 20.3%, RR 0.95, CI 0.90-0.99) compared to the women in the Routine-care group. Less babies were born small for gestational age (8.5% vs. 9.3%, RR 0.91, CI 0.85-0.99) in the Mindfetalness group. Women in the Mindfetalness group contacted healthcare due to decreased fetal movements to a higher extent than women in the Routine care group (7.8% vs. 4.3%, RR 1.79, CI 1.62-1.97). The differences remain after adjustment for potential confounders. CONCLUSIONS: Raising awareness about fetal movements through Mindfetalness decreased the rate of cesarean sections, labor inductions and small-for-gestational age babies. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02865759 ). Registered 12 August 2016, www.clinicaltrials.gov .

African midwifery students' self-assessed confidence in antenatal care: a multi-country study.

Background: Evidence-based antenatal care is one cornerstone in Safe Motherhood and educated and confident midwives remain to be optimal caregivers in Africa. Confidence in antenatal midwifery skills is important and could differ depending on the provision of education among the training institutions across Africa.Objective: The aim of the study was to describe and compare midwifery students' confidence in basic antenatal skills, in relation to age, sex, program type and level of program.Methods: A survey in seven sub-Saharan African countries was conducted. Enrolled midwifery students from selected midwifery institutions in each country presented selfreported data on confidence to provide antenatal care. Data were collected using a selfadministered questionnaire. The questionnaire consisted of 22 antenatal skills based on the competency framework from the International Confederation of Midwives. The skills were grouped into three domains; Identify fetal and maternal risk factors and educate parents; Manage and document emergent complications and Physical assessment and nutrition.Results: In total, 1407 midwifery students from seven Sub-Saharan countries responded. Almost one third (25-32%) of the students reported high levels of confidence in all three domains. Direct entry programs were associated with higher levels of confidence in all three domains, compared to post-nursing and double degree programs. Students enrolled at education with diploma level presented with high levels of confidence in two out of three domains.Conclusions: A significant proportion of student midwives rated themselves low on confidence to provide ANC. Midwifery students enrolled in direct entry programs reported higher levels of confidence in all domains. It is important that local governments develop education standards, based on recommendations from the International Confederation of midwives. Further research is needed for the evaluation of actual competence.

Haemorrhoids - A neglected problem faced by women after birth.

OBJECTIVE: To investigate the prevalence and severity of haemorrhoids after birth among first-time mothers in relation to management during the second stage of labour and to describe the women's experiences with haemorrhoids. METHOD: A mixed method explanatory sequential design was used. Nulliparous women were allocated to an intervention group for whom the second-stage of labour practice followed the MIMA model (Midwives management during second stage of labour) or to a control group for whom standard-care practice was followed. Data were collected three weeks and 1.5 years after birth. RESULT: A total of 496 (82.1%) women responded to the questionnaire three weeks after birth, 120 (70%) responded to the questionnaire 1.5 years after the birth. The women in the intervention group had fewer symptoms from haemorrhoids three weeks after birth compared to the women in the control group (adj. OR 0.6 95% CI 0.4-0.9). Half of the women in the intervention and control group (50.8%) who reported problems with haemorrhoids three weeks after birth still experienced problems after 1.5 years. The majority of all women did not seek medical care due to their symptoms. The women who described that they experienced haemorrhoids as a problem after birth felt neglected by the healthcare system. CONCLUSION: A substantial percentage of women had symptoms from haemorrhoids after birth. Many of these women felt that their problems were neglected. Women who experienced a slow birth of the baby's head and spontaneous pushing suffered less from haemorrhoids 3 weeks after birth.

Midwives experiences of participating in a midwifery research project: A qualitative study.

PROBLEM AND BACKGROUND: In an earlier research project midwives were asked to perform women-centered care focusing on the assumption that the physiological process in the second stage of labour could be trusted and that the midwives role should be encouraging and supportive rather than instructing. There is no knowledge about how midwives participating in such a research project, uses their skills and experience from the study in their daily work. AIM: The aim in this study was to investigate how midwives experienced implementing woman-centered care during second stage of labour. METHODS: A qualitative study was designed. Three focus groups and two interviews were conducted. The material was analysed using content analysis. FINDINGS: The participating midwives' experiences were understood as increased awareness of their role as midwives. The overarching theme covers three categories 1) establishing a new way of working, 2) developing as midwife, 3) being affected by the prevailing culture. The intervention was experienced as an opportunity to reflect and strengthen their professional role, and made the midwives see the women and the birth in a new perspective. CONCLUSIONS: Implementing woman-centered care during second stage of labour gave the midwives an opportunity to develop in their professional role, and to enhance their confidence in the birthing women and her ability to have a physiological birth. To promote participation in, as well as conduct midwifery research, can enhance the development of the midwives professional role as well as contribute new knowledge to the field.