Exploring continuity of care for women with prenatal diagnosis of congenital anomaly: A mixed method study.

AIMS: To map the pathway and service provision for pregnant women whose newborns require admission into the surgical neonatal intensive care unit at or soon after birth, and to examine the nature of continuity of care (COC) provided and the facilitators and barriers to woman- and family-centred care from the perspective of women/parents and health professionals. BACKGROUND: Limited research exists on current service and care pathways for families whose babies are diagnosed with congenital abnormality requiring surgery. DESIGN: A mixed method sequential design adhering to EQUATOR guidelines for Good Reporting of a Mixed Methods Study. METHODS: Data collection methods included: (1) a workshop with health professionals (n = 15), (2) retrospective maternal record review (n = 20), prospective maternal record review (17), (3) interviews with pregnant women given a prenatal diagnosis of congenital anomaly (n = 17) and (4) interviews with key health professionals (n = 7). RESULTS/FINDINGS: Participants perceived care delivered by state-based services as problematic prior to admission into the high-risk midwifery COC model. Once admitted to the high-risk maternity team women described care 'like a breath of fresh air' with a 'contrast in support', where they felt supported in their decisions. CONCLUSION: This study highlights provision of COC, in particular relational continuity between health providers and women as essential to achieve optimal outcomes. RELEVANCE TO CLINICAL PRACTICE: Provision of individualised COC offers an opportunity for perinatal services to reduce the negative consequences of pregnancy-related stress associated with diagnosis of foetal anomaly. PATIENT OR PUBLIC CONTRIBUTION: No patient or public was involved in the design, analysis, preparation or writing of this review.

The impact of midwifery continuity of care on maternal mental health: A narrative systematic review.

BACKGROUND: Systematic reviews have shown that midwifery continuity of care programs lead to improvements in birth outcomes for women and babies, but no reviews have focused specifically on the impact of midwifery continuity of care on maternal mental health outcomes. OBJECTIVE: To systematically review the available evidence on the impact of midwifery continuity of care on maternal mental health during the perinatal period. METHOD: A systematic search of published literature available through to March 2021 was conducted. A narrative approach was used to examine and synthesise the literature. RESULTS: The search yielded eight articles that were grouped based on the mental health conditions they examined: fear of birth, anxiety, and depression. Findings indicate that midwifery continuity of care leads to improvements in maternal anxiety/worry and depression during the perinatal period. CONCLUSION: There is preliminary evidence showing that midwifery continuity of care is beneficial in reducing anxiety/worry and depression in pregnant women during the antenatal period. As the evidence stands, midwifery continuity of care may be a preventative intervention to reduce maternal anxiety/worry and depression during the perinatal period.

Fathers' perceptions and experiences of support to be a parenting partner during the perinatal period: A scoping review.

AIMS AND OBJECTIVES: The aim of this study was to explore fathers' perceptions and experiences of support in the perinatal period. Change in society has seen the increased visibility of fathers being involved during pregnancy and engaging in their infants' lives and the expectation and benefits of men playing an equal and direct role in caring for their children. However, less is known about the nature of support that fathers require to facilitate this role transition. DESIGN: A scoping review was conducted in accordance with Arksey and O'Malley's six-step scoping review framework and the PRISMA-ScR guidelines. METHODS: A systematic search of CINAHL Plus, MEDLINE, the Cochrane Library, PsycARTICLES, PsycINFO, Psychology, Soc INDEX and Behavioural Sciences Collections databases for qualitative or mixed methods studies with qualitative data was undertaken. Qualitative data were extracted from original studies for coding and theme generation. Thematic synthesis was employed for the final stages of analysis. RESULTS: Overall, 23 papers were included. Men desired to fulfil their rite of passage to be an involved father to their child. This transitional process commenced with men articulating their commitment to creating a role as an involved father and to be a role model for their children. Becoming a father is seen as having a significant status in society which contributes to their self-efficacy as fathers. CONCLUSION: Fathers require support from all levels of the 'ecosystem' including policy, socio-cultural and workplace changes as well as recognition and support from partners, family, peers and in particular from health service providers. Developing the parenting partnership requires a co-production approach and commitment at macro, meso and micro levels. RELEVANCE TO CLINICAL PRACTICE: Supporting men to be engaged fathers requires policy, socio-cultural and workplace changes; however, maternity services and particularly midwives have an important role in this change.

A comparison of the Woman-centred care: strategic directions for Australian maternity services (2019) national strategy with other international maternity plans.

BACKGROUND: In 2019 the Australian government released a guiding document for maternity care: Woman-centred care strategic directions for Australian maternity services (WCC Strategy), with mixed responses from providers and consumers. The aims of this paper were to: examine reasons behind reported dissatisfaction, and compare the WCC Strategy against similar international strategies/plans. The four guiding values in the WCC strategy: safety, respect, choice, and access were used to facilitate comparisons and provide recommendations to governments/health services enacting the plan. METHODS: Maternity plans published in English from comparable high-income countries were reviewed. FINDINGS: Eight maternity strategies/plans from 2011 to 2021 were included. There is an admirable focus in the WCC Strategy on respectful care, postnatal care, and culturally appropriate maternity models. Significant gaps in support for continuity of midwifery care and place of birth options were notable, despite robust evidence supporting both. In addition, clarity around women's right to make decisions about their care was lacking or contradictory in the majority of the strategies/plans. Addressing hierarchical, structure-based obstacles to regulation, policy, planning, service delivery models and funding mechanisms may be necessary to overcome concerns and barriers to implementation. We observed that countries where midwifery is more strongly embedded and autonomous, have guidelines recommending greater contributions from midwives. CONCLUSION: Maternity strategy/plans should be based on the best available evidence, with consistent and complementary recommendations. Within this framework, priority should be given to women's preferences and choices, rather than the interests of organisations and individuals.

Creating coherent perinatal care journeys: An ethnographic study of the role of continuity of care for Danish parents in a vulnerable position.

BACKGROUND: While continuity of care is a core element of high-quality maternity care, it is potentially even more important for pregnant women and their partners who are at risk of adverse health outcomes because of psychosocial vulnerability. However, little is known about how a coherent care journey can be ensured for women and families who may require interdisciplinary and inter-sectoral services during pregnancy and the postnatal period. AIM: To explore the role of continuity of care in creating a coherent care journey for vulnerable parents during pregnancy and the postnatal period. METHODS: An ethnographic study conducted in Denmark based on interviews with, and field observations, of 26 mothers and 13 fathers receiving services due to mental health problems, young age, past substance abuse and/or adverse childhood experiences. FINDINGS: Three key findings emerged: 1). Developing relationships allowed parents to know and feel known by care providers, which helped them feel secure and reach out for support. 2). Handover of information allowed parents to feel secure as their need for support was recognised by care providers; some parents, however, felt exposed when information was shared 3). Receiving relevant services allowed parents to have their needs for support addressed, which requires easy referral pathways and coordination of services. CONCLUSION: All forms of continuity of care should be prioritised in the organisation of maternity care services for women and families in vulnerable positions. While relational continuity is important, continuity of care must also reach across providers, sectors and services to ensure coherent care journeys.

Educational programs and teaching strategies for health professionals responding to women with complex perinatal mental health and psychosocial concerns: A scoping review.

BACKGROUND: Mental health and psychosocial concerns such as domestic violence in pregnancy and after birth are significant issues. Maternal health, social and environmental contexts have a direct influence on child development and long-term health. However, midwives, nurses and other health professionals lack confidence and skills in assessing, supporting and referring women with perinatal psychosocial concerns. AIM AND OBJECTIVES: The aim of the scoping review is to review educational innovations and teaching strategies used to build skills and knowledge in health professionals and students to address psychosocial concerns including perinatal mental health, domestic violence and drug and alcohol misuse. DESIGN: A scoping review was undertaken to help identify the breadth of papers reporting educational innovations and strategies particularly to address psychosocial concerns. METHOD: Four databases CINAHL, PsychoInfo, PubMed, OvidMedline and the grey literature were searched using a diverse range of terms for papers published in English between January 2009 and December 2020. This yielded 2509 papers and after review, 34 papers were included in the scoping review. RESULTS: The 34 papers in this review found a diversity of educational initiatives and strategies delivered either face-to-face, online or in a blended mode addressing the learning needs of health professionals working with women with complex psychosocial concerns. The following characteristics in the papers were examined; focus of education, design and development, length, target audience including interprofessional focus, self-care, sensitive topics, debriefing, involving lived experience consumers and evaluation measures. PARTICIPANTS: In the studies indicated that they benefited from hearing about the individuals' lived experiences, opportunities for simulated practice and valued interprofessional learning experiences for both content and teamwork. The emergence of virtual modes offered some innovative and engaging ways to create a safe space for psychosocial education. However, the research does not provide guidance as to the best mode of delivery or length of program CONCLUSION: This scoping review provides a broad overview of innovative and diverse educational methods and strategies being used in the nursing, midwifery and health disciplines to engage students and practitioners in learning in the areas of perinatal mental health and psychosocial care. Involvement of lived experience consumers in the design and delivery of education programs can positively impact learners' knowledge and understandings of sensitive psychosocial topics. These diverse approaches could be used to shape the development and evaluation of future education programs.

"You're a 'high-risk' customer": A qualitative study of women's experiences of receiving information from health professionals regarding health problems or complications in pregnancy.

BACKGROUND: Experiencing complications in pregnancy is stressful for women and can impact on fetal and maternal outcomes. Supportive encounters with health professionals can reduce the worry women experience. Further research is needed to understand women's perspectives on communicating with their healthcare providers about their concerns. AIM: This study explored women's experiences of receiving information about pregnancy complications from healthcare providers and their interactions with multiple professionals and services during pregnancy. METHODS: This was a qualitative interpretive study. Semi-structured interviews were conducted with 20 women experiencing pregnancy complications recruited from antenatal services at two hospitals in Sydney. Inductive thematic analysis was used to analyse the data. FINDINGS: Women had a range of reactions to their diagnoses, including concern for their baby, for themselves and for their labour. Most women reported that communication with healthcare providers was distressing, they were not listened to and staff used insensitive, abrupt language. Women were also distressed by delays in education, receiving contradictory information and having to repeatedly share their stories with different health professionals. In some cases, this damaged the therapeutic relationship and reduced trust towards healthcare providers. Midwives were generally preferred over doctors because they had a more woman-centred approach. CONCLUSION: To improve women's experiences of care for pregnancy complications, it is critical to improve the communication skills of maternity service providers. Women's need for information, resources and support can best be provided by continuity of care with a named health professional, for example, a midwife working within an integrated multidisciplinary antenatal service model.

Why do some pregnant women not fully disclose at comprehensive psychosocial assessment with their midwife?

PROBLEM: While comprehensive psychosocial assessment is recommended as part of routine maternity care, unless women engage and disclose, psychosocial risk will not be identified or referred in a timely manner. We need to better understand and where possible overcome the barriers to disclosure if we are to reduce mental health morbidity and complex psychosocial adversity. AIMS: To assess pregnant women's attitude to, and reasons for non-disclosure at, comprehensive psychosocial assessment with their midwife. METHODS: Data from 1796 pregnant women were analysed using a mixed method approach. After ascertaining women's comfort with, attitude to, and non-disclosure at psychosocial screening, thematic analysis was used to understand the reasons underpinning non-disclosure. FINDINGS: 99% of participants were comfortable with the assessment, however 11.1% (N = 193) reported some level of nondisclosure. Key themes for non-disclosure included (1) Normalising and negative self-perception, (2) Fear of negative perceptions from others, (3) Lack of trust of midwife, (4) Differing expectation of appointment and (5) Mode of assessment and time issues. DISCUSSION: Factors associated with high comfort and disclosure levels in this sample include an experienced and skilled midwifery workforce at the study site and a relatively advantaged and mental health literate sample. Proper implementation of psychosocial assessment policy; setting clear expectations for women and, for more vulnerable women, extending assessment time, modifying mode of assessment, and offering continuity of midwifery care will help build rapport, improve disclosure, and increase the chance of early identification and intervention. CONCLUSIONS: This study informs approaches to improving comprehensive psychosocial assessment in the maternity setting.

A qualitative study of the impact of adverse birth experiences on fathers.

BACKGROUND: Being present during labour and birth can, for some fathers, result in feelings of fear, uncertainty, anxiety, and helplessness. Witnessing birth complications or adverse events may cause immediate and long-term anxiety and stress. In turn, this experience can impact on men's sense of self and identity as a man and father and can affect his relationship with his infant and partner. The aim of this study was to explore the immediate and longer-term impact of witnessing a complicated or adverse birth experiences on men in heterosexual relationships and their role as a father. METHODS: An interpretive qualitative approach informed the design of this study. A total of 17 fathers, one from New Zealand and sixteen from Australia participated through face to face, telephone and email interviews. The ages of the men were between 24 to 48 years, and the time since the adverse birth experience ranged from 4.5 months to 20.5 years. FINDINGS: Thematic analysis revealed three major themes representing men's experiences of witnessing a complicated birth or adverse event; 'Worst experience of my life', 'Negotiating my place: communicating with health professionals' and 'Growing stronger or falling apart'. Men were unprepared and feared for the lives of their infants and partners, they expected and wanted to be involved in the birth and the maternity care journey, instead they were pushed to the side and excluded from the labour and birth during times of emergency. Being excluded from part or all of the birth perpetuated worry and vulnerability as, at times, men were left not knowing anything about what was happening to their partners. Midwives and other health professionals' support was important to the way fathers adjusted and processed the complications of the labour and birth event. This experience impacted on their own mental health and their relationship with their baby and partner. CONCLUSION: Findings demonstrate that following a complicated or adverse birth experience, men questioned their role as a father, their place in the family and their role at the birth. There is a need to include and inform the expectant father that help is available if they experience negative feelings of hopelessness or despair. Maternity services and care providers need to involve fathers so that they feel part of the maternity care system and journey which may mitigate feelings of helplessness.

The river of postnatal psychosis: A qualitative study of women's experiences and meanings.

OBJECTIVE: This paper reports findings from a study about women's experience of postpartum psychosis which affects 1-2 women in 1000 in the first four to six weeks following childbirth. Previous research reports many women are relucent to disclose symptoms of mental ill health to healthcare professionals, although they are most likely to discuss symptoms and concerns with a health professional known to them. DESIGN: A qualitative interpretive study using semi-structured interviews. PARTICIPANTS: Ten women in Australia who had recovered from postpartum psychosis in the last ten years were interviewed. DATA ANALYSIS: Data were analysed thematically by three researchers to enhance trustworthiness. RESULTS: The women described their overall experience as traumatic and described what they saw as contributing factors such as a previous history of mental illness or a significant life event that was present before or during pregnancy; the women described how they made meaning of the symptoms they experienced, such as a lack of sleep or changes in their thoughts or behaviours; and the difficulties they experienced during recovery. The women also identified novel ways to support themselves and each other as they recovered. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Midwives require further education to recognise the symptoms of postpartum psychosis, to ask further probing questions to identify postpartum psychosis in its early stages and to support women as they recover from this illness.

Supportive encounters during pregnancy and the postnatal period: An ethnographic study of care experiences of parents in a vulnerable position.

BACKGROUND: Pregnant women and partners with psychological and/or social challenges are exposed to adverse health outcomes. It is therefore recommended that they receive targeted maternity care services. The relationship between parents and professionals is key to help parents engage with services and experience them as supportive. However, more knowledge is needed on parents' care experiences during encounters with professionals to further understand when and how these are experienced as supportive. OBJECTIVES: This study aimed at identifying the key elements of supportive care practices by exploring how parents in vulnerable positions experience their relationship and encounters with the professionals involved in their pregnancy and postnatal care. DESIGN: Ethnographic fieldwork was conducted in a Danish municipality, including 50 semi-structured interviews with parents and 51 field visits during parent-professional encounters, including informal interviews and participant observation. Using a purposive recruitment strategy, 26 women and 13 men were recruited, who varied in age, socioeconomic background and vulnerability factors. COREQ reporting guidelines were used. RESULTS: The analysis identified five themes: (a) Having a voice: Feeling listened to, (b) Being met with empathy: Feeling understood, (c) Worthy of attention: Feeling taken seriously, (d) On equal terms: Feeling like a normal family and (e) Moving in the right direction: Feeling reassured. CONCLUSION: Positive care experiences facilitate engagement with services and professionals as this contribute to parents feeling included, respected and safe. Conversely, negative care experiences leave parents feeling excluded, judged and anxious, potentially reinforcing and adding to existing feelings of anxiety and stigma. This requires that professionals have good communication skills and are able to approach parents in an open and non-judgmental way. RELEVANCE TO CLINICAL PRACTICE: Understanding the significance of supportive care practices is paramount for health visitors, midwives and other professionals involved in providing for parents in vulnerable positions during pregnancy and the postnatal period.

Emergency scenarios in maternity: An exploratory study of a midwifery and medical student simulation-based learning collaboration.

BACKGROUND AND PROBLEM: In Australia, interprofessional education has been embedded into pre-registration course accreditation standards. Little is known about Australian midwifery and medical students experiences of interprofessional learning when the focus is on emergency scenarios during birth. AIM: This study aimed to evaluate student experience of Interprofessional Simulation-Based Learning workshops focused on emergency scenarios with midwifery and medical students. METHODS: This was a descriptive, exploratory study of an educational activity designed to enhance inter-professional and collaborative learning between Bachelor of Midwifery students and Bachelor of Medicine students at a Simulation Centre in Sydney, Australia. A pre and post survey design enabled data collection before and after the 6-h simulation-based workshop. FINDINGS: A total of 45 students attended two interprofessional simulation learning days, 14 were midwifery students and 31 medical students. Students disclosed a level of apprehension in the pre workshop survey and ambivalence towards the values of collaborative simulation-based learning. Following the workshop students reported that the workshop enhanced their ability to work collaboratively in practice. Both student cohorts commented on a perceived power imbalance and a sense of each profession having to 'prove' their knowledge levels. Students stated that learning to work together in a safe environment allowed them to develop an appreciation for each other's scope of practice and responsibilities in an emergency situation. CONCLUSION: This form of collaborative learning has the potential to improve new graduate experience in the workplace, especially during emergency situations, and ultimately improve care for women and babies.

An ethnographic study of the interaction between philosophy of childbirth and place of birth.

BACKGROUND: Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. AIM: To explore how childbirth is constructed and influenced by context in three birth settings in Australia. METHOD: This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). RESULTS: All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. CONCLUSIONS: A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.

From hopelessness to some hope: A qualitative interpretive research project to improve birthing experiences in Jordan.

BACKGROUND: Many women living in Middle Eastern countries report negative, dehumanising experiences of childbirth. Finding effective ways of changing maternity care to improve women's experience is needed but is challenging. AIM: This paper explores the potential strategies to improve birthing experiences of women in Jordan and identifies the facilitators and obstacles to change. METHOD: A qualitative interpretive research design underpinned by a feminist approach was used. Seventeen community women, 14 midwives and midwifery leaders were engaged in workshops and face-to-face semi-structured interviews. Data were transcribed verbatim and thematic analysis undertaken. RESULTS: An overarching theme "From hopelessness to some hope" emerged from data analysis and comprised of two themes: 'It's hopeless-there are so many obstacles'; and 'Finding some hope for the way forward'. The community women were unhappy with the current maternity services but accepted the situation. Midwives offered explanations for the way women are treated, including that women have no voice. For these participants, the obstacles seemed almost insurmountable; however, there was some hope expressed about potential for small changes to occur. CONCLUSIONS: This study highlights the value of women and midwives sharing experiences and listening to the stories of women. Listening to women's birth stories may also be an important element of undergraduate and continuing education in Jordan. Small changes, such as promoting women's dignity by ensuring they are covered during birth are possible, but real change needs to be generated at a professional and societal level.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia.

BACKGROUND: Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia. METHODS: The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor. RESULTS: In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC. CONCLUSION: This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

Designing a model of breastfeeding support in Australia: An appreciative inquiry approach.

In Australia, one of the most frequent reasons for not breastfeeding is a previously unsuccessful experience. This qualitative study used an appreciative inquiry approach to co-design a model of peer and professional breastfeeding support, in a metropolitan area of New South Wales (NSW) Australia, in collaboration with women who have had previous negative experiences of breastfeeding. In total, 30 mothers, health professionals and peer supporters participated in a two-part study, involving interviews and a collaborative workshop. The data were analysed using content analysis. The appreciative inquiry approach led to a solution focused attitude among participants and a commitment to improving breastfeeding support. We noted a level of apathy when the participant groups were interviewed individually prior to the collective workshop. During the collaborative workshop, all three participant groups came together to look at what was currently working well and designed improvements for the future. Midwifery care was identified as important for the start of the breastfeeding journey, during pregnancy and for the first 1-2 weeks after birth, but thereafter it was community and trained peer counsellors who were prioritised for breastfeeding support. Participants identified the need for a variety of support options including face-to-face meetings, Skype meetings, phone calls and/or texting. Workshop participants emphasised the need for women, especially those with previous negative experiences, to be linked in with their local peer support community group. An appreciative inquiry approach brought together all key stakeholders to develop practice-based change which included the end user and care providers. The collaborative workshop enabled participants to come together, as individuals, rather than as designated health professionals or trained peer counsellors, or breastfeeding women with negative experiences. This led to a unified approach and a harnessing of collective energy to initiate positive change.

Integrated physical and mental healthcare: an overview of models and their evaluation findings.

BACKGROUND: Comorbid physical and mental health problems are common across the age spectrum. However, services addressing these health concerns are typically siloed and disconnected. Over the past 2 decades efforts have been made to design integrated services to address the physical and mental health needs of the population but little is known about the characteristics of effective integrated care models. The aim of the review was to map the design of integrated care initiatives/models and to describe how the models were evaluated and their evaluation findings. METHOD: Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. RESULTS: The current review identified 43 studies, describing 37 models of integrated physical and mental healthcare. Although modest in terms of evaluation design, it is evident that models are well received by consumers and providers, increase service access, and improve physical and mental health outcomes. Key characteristics of models include shared information technology, financial integration, a single-entry point, colocated care, multidisciplinary teams, multidisciplinary meetings, care coordination, joint treatment plan, joint treatment, joint assessment/joint assessment document, agreed referral criteria and person-centred care. Although mostly modest in term of research design, models were well received by consumers and providers, increased service access and improved physical and mental health outcomes. There was no clear evidence regarding whether models of integrated care are cost neutral, increase or reduce costs. CONCLUSION: Future research is needed to identify the elements of integrated care that are associated with outcomes, measure cost implications and identify the experiences and priorities of consumers and clinicians.

A survey of women in Australia who choose the care of unregulated birthworkers for a birth at home.

BACKGROUND: Anecdotally, the number of Australian women who choose unregulated birthworkers to support a homebirth without a registered midwife present is increasing. AIM: To explore the experiences and reasons why some women choose unregulated birthworkers for a homebirth, and examine what they might do if changes in legislation removed this choice. METHODS: A survey was distributed via social media networks and data were analysed using descriptive statistics. Content analysis was undertaken on open-ended questions. FINDINGS: Eighty-two women completed the survey. Most reported they achieved an undisturbed homebirth with a flexible carer who provided continuity of care and respect for their choices irrespective of risk factors. Three women whose babies died described their homebirth with an unregulated birthworker as the worst experience of their life. Motivators for choosing an unregulated birthworker to support homebirth were: previous negative and traumatising birth experiences; limited choice; and lack of access to midwifery led models of care within mainstream services. Only a third of the women in this study said they would birth in a hospital if legislation prevented their access to an unregulated birthworker's support for a future birth. CONCLUSION: Maternity services in Australia do not meet all women's needs, leaving some feeling no other option exists but to seek an unregulated birthworker to support a homebirth. Previous negative experiences with maternity healthcare providers, inflexible systems of care, and limited access to funding for homebirth with privately practising midwives were identified as motivating factors. These issues require solutions to prevent homebirth going underground.

The role, practice and training of unregulated birth workers in Australia: A mixed methods study.

BACKGROUND: In Australia, the provision of homebirth services by unregulated birthworkers (doulas, ex-registered midwives, traditional midwives and lay workers) has increased. Accessing a homebirth with a registered midwife via mainstream services is limited. Concern is growing that new legislation aimed at prohibiting unregulated birthworkers practice may result in homebirth going underground. AIM: To explore the role, practice and training of unregulated birthworkers in Australian and establish what they would do if legislation prohibited their practice. METHODS: This study used a mixed methods sequential exploratory design to explore the practice, training and role of unregulated birthworkers in Australia. In phase one, four unregulated birthworkers were interviewed in-depth and the findings informed the development of a survey in phase two. This was distributed nationally through two consumer websites, social media, Facebook and email. Data from both phases were integrated. FINDINGS: Unregulated birthworkers in Australia provide homebirth services to women with high and low-risk pregnancies when this choice is unavailable or unacceptable within mainstream services. They operate covertly to protect their practice and avoid the scrutiny of authorities. Unregulated birthworkers can be experienced and trained in childbirth care and practice, much like a midwife working within a holistic paradigm of care. CONCLUSION: Unregulated birthworkers believe they provide women with the homebirth service they want but cannot access. Mainstream service providers need to listen to consumer criticisms, as women seek answers outside the system. Change is needed to improve and align services with women's expectations of homebirth.

The effect of complementary medicines and therapies on maternal anxiety and depression in pregnancy: A systematic review and meta-analysis.

BACKGROUND: Depression and anxiety are common during the antenatal and postnatal period, and are known to have a significant impact on the woman and her unborn infant. Pregnant women state a preference for non-pharmacological treatment options, and use complementary medicines and therapies to manage these symptoms. We examined the effectiveness and safety of these modalities on depression and anxiety during pregnancy. METHODS: CENTRAL, EMBASE and PubMed databases were searched for randomised controlled trials comparing complementary therapies and medicines to a control, for pregnant women with depression or anxiety. The primary outcome measure was antenatal depression or anxiety. RESULTS: Twenty randomised controlled trials containing 1092 women were included in the review. We found some evidence of reduced antenatal depression from three modalities. Acupuncture reduced the number of women diagnosed with antenatal depression (RR 1.68, 95% CI 1.06-2.66, 1 trial). Massage reduced the severity of antenatal depression in one trial of 149 women (SMD -0.73, 95%CI -1.07--0.39). One small trial of bright light therapy found reduced antenatal depression (RR 4.80, 95% CI -8.39--1.21, 27 women). There was no evidence of a reduction in depression and anxiety from relaxation, yoga, mindfulness and fish oils. Overall the risk of bias was high or unclear for the majority of studies. LIMITATIONS: There are few high quality randomised controlled trials of complementary medicines and therapies examining the effect on anxiety and depression. CONCLUSION: Acupuncture, bright light therapy, and massage may reduce antenatal depression. There is a need for high quality and larger studies that include postnatal follow up and maternal and neonatal outcomes.