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

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

The completion of partograms: knowledge, attitudes and practices of midwives in a public health obstetric unit in Bloemfontein, South Africa.

INTRODUCTION: most maternal and 24.3% of infant deaths occur during childbirth. Interventions during childbirth may reduce maternal and neonatal deaths. The Guidelines for maternity care in South Africa (2015) stipulates that all observations during labour should be recorded on a partogram. The objective of this study was to assess the knowledge and attitudes of nursing personnel and to evaluate their practices of completing partograms at National District Hospital, South Africa. METHODS: a two-phase, quantitative, cross-sectional, descriptive study design was used. In phase 1, the knowledge and attitudes of midwives and nurses were evaluated. Midwives and nurses completed anonymous, self-administered questionnaires that assessed their knowledge and attitudes. In Phase 2, partogram practices were measured by assessing completed partograms using a data collection tick sheet. RESULTS: twelve of the 17 nursing personnel completed the questionnaires. More than 90% of participants answered basic partogram knowledge questions correctly, but only two thirds knew the criteria for obstructive labour and just more than half that for foetal distress. Participants displayed a positive attitude toward the use of partograms. Of the 171 randomly selected vaginal deliveries during the study period, only 57.1% delivered with a completed partogram. Most elements of foetal monitoring and progress of labour scored above 80%, however, for maternal monitoring scored poorly in 26.4% of cases. CONCLUSION: although 71.4% of partograms scored more than 75% for completion, the critical components that influence maternal and foetal death, like the identification of foetal distress, maternal wellbeing and progress of labour, were lacking.

Experiences of registered nurse prescribers; a qualitative study.

Aims: This study aimed to investigate the experiences of registered prescribers and their perceptions of the enablers and barriers to registered prescribing and the value of this fledgling role. Background: The role of prescribing has been extended to registered nurses in New Zealand. By adding the designated prescribing role to a nurse's role, their scope of practice expands and nurses are able to provide patients with holistic care while achieving greater independence and role satisfaction. Yet new nurse prescribers can experience anxiety and fear when confronted with the reality of the responsibility of prescribing. Methods: Sixteen semi-structured interviews were conducted with registered nurse prescribers across New Zealand. Data were analysed using a general inductive approach and thematic analysis utilised to identify themes and sub-themes. Results: Sixteen registered nurse prescribers participated in the study. Three main themes emerged with sub-themes: ability to expand practice, improving access to care, and importance of working in a collaborative team. Participants explained how they enjoyed the challenge and responsibility of the new prescribing role yet were frustrated with the realities of the restrictions of what they could actually prescribe and in some cases lack of role recognition. Registered nurse prescribing also improved access to care as nurses felt they provided more comprehensive care, resulting in reduced wait times, better continuity of care and a reduction in patient costs. The participants highlighted the importance of working in a collaborative team and believed their ability to prescribe maximised clinician time, however cautioned the need for on-going clinical mentorship and a prepared and supportive work environment. Conclusions: The addition of registered nurse prescribing provides a number of advantages to individual nurses in terms of career development and job satisfaction, and to patients and the health care system. The benefits to health care consumers and the health care system align directly to health care priorities of improving equity and access to care. Impact statement: Registered nurse prescribers perceive a number of advantages to the addition of prescribing to their own practice and benefits to patients and the health care system by enabling more accessible and cost-effective care.

Nurse- and Midwife-Led HIV Services in Eastern and Southern Africa: Challenges and Opportunities for Health Facilities.

In eastern and southern Africa, much is unknown about implementation of nurse-initiated and managed antiretroviral therapy (NIMART). The purpose of this study was to identify perceived barriers and facilitators of NIMART for the prevention of mother-to-child transmission and pediatric HIV services in high-volume, high HIV-burden health facilities across this region. A total of 211 nurses, midwives, and nurse midwives and 62 supervisors from 30 health facilities in 11 countries participated in this mixed-methods evaluation. The findings show that although nurses, midwives, and nurse midwives clearly had the authority to provide NIMART services, they did not necessarily feel that they were well prepared and supported to do so. Deficits in supportive supervision and clinical mentorship were viewed as substantial challenges to effective provision of NIMART for the prevention of mother-to-child transmission and pediatric HIV services-particularly with respect to pediatric HIV services. Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support.

Evaluation of a student-led midwifery group practice: A woman's perspective.

BACKGROUND: . OBJECTIVE: To evaluate women's experiences of a student-led midwifery group practice. DESIGN: A mixed methods design was used to examine women's experiences and level of satisfaction about a student-led midwifery model of care. An on-line survey elucidated women's levels of satisfaction and experiences with the student-led midwifery group practice. The online survey was sent to all women (n = 25) who were receiving care from third year Bachelor of Midwifery students in 2018 via email up to 6 weeks postnatally. The online survey was distributed in the first instance to obtain baseline information about the importance of this student-led midwifery group practice and so the survey information was linked to the in-depth interview in the analysis for the purpose of identifying if the women were primiparous or multiparous. Women (n = 9) were invited to participate in an in-depth interview by self-opting on the survey and this extra data provided a richer understanding about the level of satisfaction about woman-centred care led by midwifery students. Retrospective data were also collected from the Maternity database - E-Maternity about birth outcomes. SETTING: A tertiary teaching public hospital in New South Wales (NSW). PARTICIPANTS: Fifteen women participated in an online survey. Five primiparous and four multiparous women opted to be involved in the in-depth interviews on the online survey. MEASUREMENTS AND FINDINGS: Analysis in SPSS provided descriptive statistics including frequencies and percentages of data including birth outcomes. Simple correlations enabled associations to be established between levels of satisfaction, individualised care, quality of care, benefits and anxiety during pregnancy. The overarching themes from the qualitative findings identified the students' presence for the women as the most important component of the women's journey. The four main themes that emerged from the study included: familiarity of the caregiver, staying informed on the journey, feeling supported and reassured by their expertise, and control and decisions over birth events. KEY CONCLUSIONS: For a variety of reasons, women valued the presence of the students throughout their childbearing journey, including valuing the woman's private space during labour and her time with her partner. This combination of pedagogical approaches provides an alternative to the current placement approach, which includes working shifts in all areas of maternity. This approach will better support midwifery students to achieve the skills necessary to provide a continuity of care experience (CoCE) amongst a small team by a student-led midwifery group practice that is supported by a registered midwife in the antenatal clinic. The midwifery student is able to develop a relationship with the woman as a component of the CoCE under the guidance of a registered midwife and this is an important underpinning of the philosophy of woman-centred care. IMPLICATIONS FOR PRACTICE: This model of care provides evidence that women do value the students' support and presence throughout their experience and that the benefits of this model should be offered to all women as a normal component of their midwifery care.

Recommendations for spiritual care in cancer patients: a clinical practice guideline for oncology nurses in Iran.

BACKGROUND: In spite of the necessity of implementing spiritual care practices for cancer patients, there is no clear process in this regard in palliative care programs of the health system of countries. The present study was designed with the aim of developing a clinical practice guideline of spiritual care in cancer patients for oncology nurses in the current context. METHODS: This is a multi-method study which was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline. A research committee consisting of four focal and 16 secondary members was formed. The stages included determining the scope of the study, developing guideline (a qualitative study and a systematic review, triangulation of the data, and producing a preliminary draft), consultation stage (validation of the guideline in three rounds of the Delphi study), as well as revision and publication stages. RESULTS: The clinical guideline of spiritual care with 84 evidence-based recommendations was developed in three main areas, including the human resources, care settings, and the process of spiritual care. CONCLUSIONS: We are hoping by applying this clinical guideline in oncology settings to move towards an integrated spiritual care plan for cancer patients in the context of our health system. Healthcare organizations should support to form spiritual care teams under supervision of the oncology nurses with qualified healthcare providers and a trained clergy. Through holistic care, they can constantly examine the spiritual needs of cancer patients alongside their other needs by focusing on the phases of the nursing process.

Umbilical Cord Practices of Members of the American College of Nurse-Midwives.

INTRODUCTION: Mercer et al surveyed members of the American College of Nurse-Midwives (ACNM) about their umbilical cord clamping practices in 2000. Over the last 20 years, a significant body of research supporting delayed cord clamping (DCC) has been published. The purpose of this study was to learn how midwives today manage the umbilical cord at birth. METHODS: To better understand the current practices of midwives, in 2017, a national online survey of ACNM members was conducted. A total of 24 questions were asked about DCC, cord milking, specific clinical circumstances, and the presence of policies or guidelines. RESULTS: A total of 5306 surveys were sent with 1106 responses. After applying inclusion criteria, 1050 were available for analysis. Respondents practiced in all settings: home, birth centers, and hospitals. Compared with 2000, a 46% increase in the practice of DCC was identified. In this study, 98% of the participants reported facilitating DCC for full-term vaginal births as compared with 67% in 2000. In addition, 25% practiced DCC for near-term and 65% for preterm neonates. Cord milking was practiced by 37% of participants. When asked about barriers to practicing DCC, 54% of participants identified time pressures to hand off the newborn as the greatest detriment. It was challenging to practice DCC in situations wherein the newborn needed resuscitation or in breech births. Far fewer midwives practice cord milking compared with DCC. DISCUSSION: The survey results suggest there has been an increase in the practice of DCC over the last 20 years. Cord milking is not as widely practiced as DCC, and respondents were less likely to be convinced by the evidence for cord milking. This speaks to the opportunity for more education for midwives. There is also a need for clinical guidelines that address umbilical cord management when challenging circumstances arise such as breech birth, shoulder dystocia, and the need for resuscitation.

Implementation of a standardized nurse initiated protocol to manage severe hypertension in pregnancy.

Objectives: Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality, studies have shown that standardized protocols for treating severe hypertension improves outcomes. Our goal was to examine the effects of a protocol for treating severe hypertension.Methods: Using quality improvement methodology, we developed an evidence-based nurse-initiated protocol for management of severe hypertension. We used a before and after study design, with the primary outcome of time to administration of antihypertensive medications and time to achieve blood pressure control. Secondary outcomes included medication usage, time to repeat blood pressure, and proportion of women receiving appropriate treatment. Statistical analysis was completed with Stata, using data medians, 95% confidence intervals and a rank-sum test.Results: Data was collected for 5 months before and 5 months after protocol implementation, with 67 patients included before and 125 patients after implementation. The median time to treatment of severe range blood pressure decreased from 25 min before to 11 min after protocol implementation, p <.001. Twenty-four% of women were treated within 15 min before and 60.6% were treated within 15 min after protocol implementation. Median time required to regain sustained mild range blood pressure was reduced from 45 min before to 41 min after protocol implementation, p = .004. 67.5% of women regained mild range blood pressure within 60 min before and 81.9% achieved blood pressure control within 60 min after protocol implementation. These improved outcomes were evident within the first month after protocol implementation and remained stable throughout the follow-up period.Discussion: Implementation of an evidence-based nurse-initiated protocol for the treatment of severe hypertension in pregnancy decreases the time required to administer antihypertensive medication, time required to regain blood pressure control and nonbeneficial clinical variation. In addition, these benefits were achieved rapidly within a large hospital setting.

Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review.

PROBLEM: There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia's Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use. OBJECTIVE: To critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement. METHOD: A search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria. FINDINGS: Although singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers. CONCLUSION: Barriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual's support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement's use in midwifery.

Role of the Advanced Nurse Practitioner Within Teenage and Young Adult Oncology. What is the Impact on Patient and Staff Experience of a New Nurse Practitioner Role to a Teenage and Young Adult Service?

Background: Advanced Practice is recognized by the Royal College of Nursing as a distinctive level of practice encompassing direct care provision, education, research, and management. Advanced Nurse Practitioners (ANP) are educated to MSc level and assessed as competent in their field. A teenage and young adult advanced nurse practitioner (TYA ANP) was introduced in 2015, one of few within the United Kingdom. This service evaluation assesses the impact of the new role on patient and staff experience. Aims/Objectives: To evaluate the impact of TYA ANP role on the experience of TYA oncology patients and the multidisciplinary team (MDT) and to assess perception of quality, safety, and efficiency of this role. Methodology: Retrospective data collection using Australia Nurse Practitioner Study Questionnaire to MDT and patients treated within the TYA unit since the ANP role was introduced. Descriptive statistics were used to analyze outcomes of the data collected. Results: Eighty-six percent of patients and 90% of staff felt they understood the ANP role. While 100% of patients felt the TYA ANP service was a success, met their needs, prescribed correctly, offered holistic and safe care, and had a positive impact on care. Furthermore, 86% of patients felt the TYA ANP service was easy to use and 90% of staff felt the TYA ANP service met the needs of the patients. Discussion/Conclusion: Overall patients and staff reported a positive experience particularly on correct diagnosis, safe prescribing, and having a positive impact on care. Areas for improvement include wider understanding of the role.

Relative effectiveness and cost-effectiveness of the midwifery-led care in Nova Scotia, Canada: A retrospective, cohort study.

OBJECTIVES: To compare neonatal and maternal outcomes, and the relative risk of interventions between mothers attended to by midwives, general practitioners, and obstetricians, and to assess the cost-effectiveness of the employee-model of midwifery-led care in Nova Scotia, Canada, when compared with general practitioners. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective cohort study involving routinely collected clinical and administrative data from all low-risk births from January 1st, 2013 to December 31st, 2017. There were 24,662 observations. MEASUREMENTS: Descriptive statistics were used to summarise the mother's socio-demographic characteristics. We used a nearest-neighbour matching estimator in assessing differences in outcomes, and generalized linear models in the estimation of the risks of interventions, adjusting for potential confounders. An analytic decision tree served as the vehicle for the cost-effectiveness analysis, assessed using the net monetary benefit approach. All health care resources utilized were measured and valued. Neonatal intensive care admissions avoided was the measure of outcome. We performed probabilistic sensitivity and subgroup analyses. FINDINGS: Mothers attended to by midwives spent less time at the hospital during birth admissions, were less likely to have interventions, instrumental births, and more likely to have exclusive breastfeeding at discharge from birth admission. There were no differences in Apgar scores and neonatal intensive care unit admissions. The employee-model of midwifery-led care was found to be cost-effective. KEY CONCLUSIONS: The midwifery program is both effective and cost-effective for low-risk pregnancies IMPLICATIONS FOR PRACTICE: Increasing the number of midwives will increase access and represents value for money.

Local treatment of pressure ulcers in long-term care: a correlational cross-sectional study.

OBJECTIVE: To analyse the treatment of pressure ulcers (PU) in long-term care. METHOD: In this correlational cross-sectional study, data was collected between November 2015 and January 2016 from older people with PUs in private and public long-term care facilities in Finland. Data collection was conducted by trained nurses using the Pressure Ulcer Patient Instrument (PUP-Ins). Outcomes measured were: prevalence and localisation of PU, local PU treatment, frequency (how often/week/day) and duration (minutes/week or day) of PU treatment. RESULTS: In total, 112 patients with 158 PUs were identified (a prevalence rate of 5%). PUs were located most often on the heel (38%), hip (13%), buttocks (10%) and lateral malleolus (9.5%). The most frequently used PU treatment was skin protecting agents and local wound care products. The most typical treatment in category I, II and III PUs were foam dressings. In category III PUs, ribbon gauze dressings were also used. The most typical products for category IV PUs were complex dressings. Category I PUs received more treatment per day or week than other categories of PUs. CONCLUSION: PU treatment is inconsistent and often conducted with varying methods and products. Holistic patient care must be the focus. Nurses in long-term care settings might benefit from in-depth in-service education focusing on the treatment of PUs. More research is needed about nurses' competence in PU treatment.

Evaluation of the adherence of distress screening with the distress thermometer in cancer patients 4 years after implementation.

PURPOSE: Identifying and assessing psychosocial distress with an appropriate screening instrument is essential when caring for cancer patients. Since 2012, the distress thermometer (DT) has been used by nurses for all cancer inpatients at the Comprehensive Cancer Center Zurich. We wanted to identify nurses' adherence to the screening protocol, differences between screened and not screened patients and the relationship between screening rate and productivity. METHODS: This retrospective descriptive study used screening and referral data as well as socioeconomic and disease-related data of inpatients at the Comprehensive Cancer Center Zurich. This was collected from the electronic patient documentation system. Additionally, data showing the productivity of all wards was used. All data were analyzed descriptive. RESULTS: Since 2012, 40.6% (4541) of the 11,184 patients have been screened. The screening rate was initially significantly lower but settled at 40% after 2 years. There was a higher screening rate among Swiss, married, male, and emergency patients and patients with hematology diseases, brain tumors, or head and neck cancer (p < 0.001). Every fourth patient with a moderate to severe distress level requested referral to a psychosocial service. Significantly more screened patients were referred to the social service (44.7%) than to the psycho-oncology service (9.4%). Only 22.9% of all referrals were made on the day of screening or a day later. There were only two wards of 15 with a significant relationship between productivity and screening rate. CONCLUSIONS: Screening is useful in recognizing distress among patients, but screening practice needs to be reconsidered.

Genomic Literacy of Registered Nurses and Midwives in Australia: A Cross-Sectional Survey.

PURPOSE: Registered nurses and midwives require a degree of genomic literacy if they are to adequately communicate with other healthcare professionals and provide optimal care to patients, their families, and the community. Several studies have been conducted internationally to assess the genomic literacy of nurses; however, the genomic literacy of Australian registered nurses and midwives has not been investigated. The aim of this study was to measure the genomic literacy of Australian registered nurses and midwives through assessing participants' understandings of genomic concepts most critical to nursing and midwifery practice, as well as their perceived knowledge and attitude towards genomics in nursing and midwifery practice. DESIGN: Cross-sectional survey of Australian registered nurses and midwives using the Genomic Nursing Concept Inventory (GNCI© ), a 31 multiple-choice question survey instrument. Participants were recruited via two key Australian nursing and midwifery organizations over an 8-month period in 2016. METHODS: Descriptive and inferential statistical techniques were used to calculate the total GNCI© score and scores on individual subcategories, as well as relationships between demographic variables and GNCI© scores. FINDINGS: Most respondents worked as clinicians (71.4%) in a hospital or hospital-based setting (61.8%). Most registered nurses (80.5%) and midwives (97.2%) reported that genetics was relevant to clinical practice; however, over 80% of registered nurses and midwives believed their knowledge of genetics was poor or average. Genomic knowledge was assessed using the GNCI© . Scores ranged from 3 to 29 (out of a possible 31), with a mean score of 13.3 (SD 4.559) based on 253 (N = 253) respondents, indicating that genomic literacy is low. There was a significant difference between genomic knowledge scores and education and training level (p = .036). CONCLUSIONS: The genomic literacy of registered nurses and midwives in Australia is low. More must be done to ensure Australian registered nurses and midwives have an adequate level of genomic literacy to provide optimal care to patients, their families, and the community. CLINICAL RELEVANCE: Modern medicine requires a healthcare workforce that is literate in genomics. Findings from this study may serve as the catalyst to improve the genomic literacy of the Australian nursing and midwifery workforce, allowing for improved health outcomes for individuals and the wider Australian public.

Healthcare providers' gestational weight gain counselling practises and the influence of knowledge and attitudes: a cross-sectional mixed methods study.

OBJECTIVE: To understand current gestational weight gain (GWG) counselling practices of healthcare providers, and the relationships between practices, knowledge and attitudes. DESIGN: Concurrent mixed methods with data integration: cross-sectional survey and semistructured interviews. PARTICIPANTS: Prenatal healthcare providers in Canada: general practitioners, obstetricians, midwives, nurse practitioners and registered nurses in primary care settings. RESULTS: Typically, GWG information was provided early in pregnancy, but not discussed again unless there was a concern. Few routinely provided women with individualised GWG advice (21%), rate of GWG (16%) or discussed the risks of inappropriate GWG to mother and baby (20% and 19%). More routinely discussed physical activity (46%) and food requirements (28%); midwives did these two activities more frequently than all other disciplines (P<0.001). Midwives interviewed noted a focus on overall wellness instead of weight, and had longer appointment times which allowed them to provide more in-depth counselling. Regression results identified that the higher priority level that healthcare providers place on GWG, the more likely they were to report providing GWG advice and discussing risks of GWG outside recommendations (ß=0.71, P<0.001) and discussing physical activity and food requirements (ß=0.341, P<0.001). Interview data linked the priority level of GWG to length of appointments, financial compensation methods for healthcare providers and the midwifery versus medical model of care. CONCLUSIONS: Interventions for healthcare providers to enhance GWG counselling practices should consider the range of factors that influence the priority level healthcare providers place on GWG counselling.

The role of nurse specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse specialist services.

OBJECTIVES: International evidence suggests the diabetes nurse specialist (DNS) has a key role in supporting integrated management of diabetes. We examine whether hospital and community DNS currently support the integration of care, examine regional variation in aspects of the service relevant to the delivery of integrated care and identify barriers to service delivery and areas for improvement. DESIGN: A cross-sectional survey of hospital and community-based DNS in Ireland. METHODS: Between September 2015 and April 2016, a 67-item online survey, comprising closed and open questions on their clinical role, diabetes clinics, multidisciplinary working, and barriers and facilitators to service delivery, was administered to all eligible DNS (n=152) in Ireland. DNS were excluded if they were retired or on maternity leave or extended leave. RESULTS: The response rate was 66.4% (n=101): 60.6% (n=74) and 89.3% (n=25) among hospital and community DNS, respectively. Most DNS had patients with stable (81.8%) and complicated type 2 diabetes mellitus (89.9%) attending their service. The majority were delivering nurse-led clinics (81.1%). Almost all DNS had a role liaising with (91%), and providing support and education to (95%), other professionals. However, only a third reported that there was local agreement on how their service should operate between the hospital and primary care. Barriers to service delivery that were experienced by DNS included deficits in the availability of specialist staff (allied health professionals, endocrinologists and DNS), insufficient space for clinics, structured education and issues with integration. CONCLUSIONS: Delivering integrated diabetes care through a nurse specialist-led approach requires that wider service issues, including regional disparities in access to specialist resources and formalising agreements and protocols on multidisciplinary working between settings, be explicitly addressed.

Comparison of Support for Breastfeeding Beyond 12 Months of Age from Conventional and Alternative Pediatric Primary Care Providers.

OBJECTIVE: Conventional medicine pediatric care providers (e.g., pediatricians) have been shown to be influential in women's decisions to initiate and sustain breastfeeding. Alternative pediatric care providers (e.g., naturopaths and chiropractors) may also provide breastfeeding support, but this has not been the subject of prior research. Our objective was to compare breastfeeding mothers' perceptions of support from these two provider types in a large sample of women who breastfed for more than 12 months. METHODS: We conducted a cross-sectional study of 49,091 U.S. women through online questionnaire distributed through peer breastfeeding groups. We used log-binomial regression to compare those who used an alternative pediatric healthcare provider to care for their child to those who used a conventional provider on perceptions of support and key factors influencing the decision to breastfeed for more than 12 months. RESULTS: Those who used an alternative provider were more likely to discuss breastfeeding (Adj RR = 1.25, 95% CI 1.17-1.33), feel comfortable discussing breastfeeding (Adj RR = 1.17; 95% CI 1.15-1.19), and feel supported by the provider (Adj RR = 1.25; 95% CI 1.23-1.28). However, providers' recommendations were not important factors in these women's decision to breastfeed beyond 12 months of age. CONCLUSIONS: Mothers who used an alternative care provider as their child's primary source of healthcare rated the provider's breastfeeding support more favorable than those who used a conventional provider (usually a pediatrician). Improving breastfeeding support may be one way to retain families in conventional pediatric primary care, and thereby, ensure children receive comprehensive, evidence-based care.

Midwife-led maternity care in Ireland - a retrospective cohort study.

BACKGROUND: Midwife-led maternity care is shown to be safe for women with low-risk during pregnancy. In Ireland, two midwife-led units (MLUs) were introduced in 2004 when a randomised controlled trial (the MidU study) was performed to compare MLU care with consultant-led care (CLU). Following study completion the two MLUs have remained as a maternity care option in Ireland. The aim of this study was to evaluate maternal and neonatal outcomes and transfer rates during six years in the larger of the MLU sites. METHODS: MLU data for the six years 2008-2013 were retrospectively analysed, following ethical approval. Rates of transfer, reasons for transfer, mode of birth, and maternal and fetal outcomes were assessed. Linear-by-Linear Association trend analysis was used for categorical data to evaluate trends over the years and one-way ANOVA was used when comparing continuous variables. RESULTS: During the study period, 3,884 women were registered at the MLU. The antenatal transfer rate was 37.4% and 2,410 women came to labour in the MLU. Throughout labour and birth, 567 women (14.6%) transferred to the CLU, of which 23 were transferred after birth due to need for suturing or postpartum hemorrhage. The most common reasons for intrapartum transfer were meconium stained liquor/abnormal fetal heart rate (30.3%), delayed labour progress in first or second stage (24.9%) and woman's wish for epidural analgesia (15.1%). Of the 1,903 babies born in the MLU, 1,878 (98.7%) were spontaneous vaginal births and 25 (1.3%) were instrumental (ventouse/forceps). Only 25 babies (1.3%) were admitted to neonatal intensive care unit. All spontaneous vaginal births from the MLU registered population, occurring in the study period in both the MLU and CLU settings (n = 2,785), were compared. In the MLU more often 1-2 midwives (90.9% vs 69.7%) cared for the women during birth, more women had three vaginal examinations or fewer (93.6% vs 79.9%) and gave birth in an upright position (standing, squatting or kneeling) (52.0% vs 9.4%), fewer women had an amniotomy (5.9% vs 25.9%) or episiotomy (3.4% vs 9.7%) and more women had a physiological management of third stage of labour (50.9% vs 4.6%). CONCLUSIONS: Midwife-led care is a safe option that could be offered to a large proportion of healthy pregnant women. With strict transfer criteria there are very few complications during labour and birth. Maternity units without the option of MLU care should consider its introduction.

[The Professional Practice of Midwives in Home-based Postnatal Care: A Literature Analysis]. / Die berufliche Praxis von Hebammen in der ambulanten Wochenbettbetreuung: eine Literaturanalyse.

Due to the reduction of the length of stay in hospital, postnatal care today takes place primarily in the ambulant sector. Midwives provide the health care and support young families. This literature study examines home-based postnatal care from the perspectives of midwives with the aim of exploring how midwives provide postnatal care and what influencing factors exist. A systematic literature search was conducted. Studies that integrated the perceptions of midwives during their work in home-based postpartum care were included. A thematic analysis of the selected articles was undertaken. Besides monitoring the health and well-being of mother and child, the focus of postnatal care is on psychosocial aspects and on support and advice on issues concerning the new situation and structural changes in the family. However, midwives do not always feel sufficiently prepared for dealing with complex psychosocial issues and require extra knowledge and better access to information. Besides temporal limitations of midwives, continuity of care as well as different care approaches are also relevant. Home-based postnatal care constitutes complex professional procedures during an important period of life of women and their families. Besides ensuring continuity of care, appropriate knowledge resources and midwifery skills are required. The development of theory-guided concepts, improved training and further training programmes as well as a clearly defined provider contract can support the professional behaviour patterns of midwives.