Woman-centred care and integrated electronic medical records within Australian maternity settings: Point prevalence audit and observational study.

OBJECTIVE: Transition to paperless records brings new challenges to midwifery practice across the continuum of woman-centred care. There is limited and conflicting evidence on the relative benefits of electronic medical records in maternity settings. This article aims to inform the use of integrative electronic medical records within the maternity services' environment with attention to the midwife-woman relationship. DESIGN: This descriptive two-part study includes 1) an audit of electronic records in the early period following implementation (2-time points); and 2) an observational study to observe midwives' practice relating to electronic record use. SETTING: Two regional tertiary public hospitals PARTICIPANTS: Midwives providing care for childbearing women across antenatal, intrapartum and postnatal areas. FINDINGS: 400 integrated electronic medical records were audited for completeness. Most fields had high levels of complete data in the correct location. However, between time 1 (T1) and time 2 (T2), persistent missing data (foetal heart rate documented 30 minutely T1 36%; T2 42%), and incomplete or incorrectly located data (pathology results T1:63%; T2 54%; perineal repair T1 60%; T2 46%) were identified. Observationally, midwives were actively engaged with the integrative electronic medical record between 23% to 68% (median 46%; IQR 16) of the time. CONCLUSION: Midwives spent a significant amount of time completing documentation during clinical episodes of care. Largely, this documentation was found to be accurate, yet exceptions to data completeness, precision and location remained, indicating some concerns with software usability. IMPLICATIONS FOR PRACTICE: Time-intensive monitoring and documentation may hinder woman-centred midwifery care.

The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature.

PROBLEM: Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice. BACKGROUND: Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences. AIMS: To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice. FINDINGS: Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice. DISCUSSION: Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system. CONCLUSIONS: There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.

Labouring Together: Women's experiences of "Getting the care that I want and need" in maternity care.

OBJECTIVE: Poor interprofessional collaboration and lack of decision-making with women have been identified as being detrimental to the quality, safety, and experience of maternity care. The aim of the Labouring Together study was to explore childbearing women's preferences for and experiences of collaboration and control over decision-making in maternity care. DESIGN: A sequential, mixed-method, multi-site case study approach was used to explore the perceptions and experiences of childbearing women regarding collaboration and decision-making. Women's preferred role for decision-making compared to the actual experiences, and the influences upon their preferences and experiences of collaboration were explored using semi-structured interviews. An inductive approach was used for qualitative analysis of interviews, and cross-case analyses were conducted using replication logic. SETTING: Postnatal wards of 1 private and 3 public maternity services in both metropolitan and regional Victoria, Australia. PARTICIPANTS: Postnatal women, over the age of 18 years (n=182). FINDINGS: Half (48.3%) of the participants indicated a preference for a shared decision-making role and 35% preferred an active role. Only 16.7% participants indicated a preference for a passive role, however 24.4% of women reported experiencing a passive decision-making role during their maternity care. Statistically significant differences were also identified between preferences for and experiences of decision-making among women who chose the private obstetrician model of maternity care compared to the public maternity care system. Negative impacts upon women's autonomy over decision-making included: poor access to midwifery models of care; poor access to relational continuity of care; poor understanding of the rights of the woman; inadequate information for women about the risks and benefits of all proposed interventions; and a bureaucratic style of decision-making based upon a dominant discourse of risk avoidance that could ultimately veto the woman's choice. KEY CONCLUSIONS: Despite evidence of the benefits for women of having autonomy over decision-making in their own care, fundamental barriers were identified that hindered women's participation in collaboration in maternity care. Shared decision-making with childbearing women is not routine practice in maternity care in Victoria, Australia. IMPLICATIONS FOR PRACTICE: Relational continuity of care is imperative to promote the autonomy of childbearing women and an environment conducive to women's active engagement in maternity care and participation in shared decision-making.

Influences on drinking choices among Indigenous and non-Indigenous pregnant women in Australia: A qualitative study.

Despite women's awareness that drinking alcohol in pregnancy can lead to lifelong disabilities in a child, it appears that an awareness alone does not discourage some pregnant women from drinking. To explore influences on pregnant women's choices around alcohol use, we conducted interviews and group discussions with 14 Indigenous Australian and 14 non-Indigenous pregnant women attending antenatal care in a range of socioeconomic settings. Inductive content analysis identified five main influences on pregnant women's alcohol use: the level and detail of women's understanding of harm; women's information sources on alcohol use in pregnancy; how this information influenced their choices; how women conceptualised their pregnancy; and whether the social and cultural environment supported abstinence. Results provide insight into how Indigenous Australian and non-Indigenous pregnant women understand and conceptualise the harms from drinking alcohol when making drinking choices, including how their social and cultural environments impact their ability to abstain. Strategies for behaviour change need to: correct misinformation about supposed 'safe' timing, quantity and types of alcohol; develop a more accurate perception of Fetal Alcohol Spectrum Disorder; reframe messages about harm to messages about optimising the child's health and cognitive outcomes; and develop a holistic approach encompassing women's social and cultural context.

Imminent birth education for rural and remote settings: An evaluation study.

OBJECTIVE: To describe the development and evaluation of an educational resource that aimed to provide the non-midwifery workforce in rural and remote health facilities with basic knowledge and skills to assist women who present when birth is imminent. DESIGN: Descriptive methods using surveys were employed to evaluate the resource named the Imminent Birth Education Program. PARTICIPANTS: Health professionals employed in Queensland Health rural and remote non-birthing facilities. INTERVENTION: An evidence-based, blended educational program comprising an online component, a face-to-face workshop and an education package for midwives to facilitate the workshop in their health service. RESULTS: More than 600 participants completed the online course component, and the majority of these participants were employed in non-birthing facilities. Throughout the project, two project officers facilitated face-to-face workshops, training participants to facilitate the workshop in their own health services. The reach of the Imminent Birth Education Program was statewide with clinical staff from all 16 Hospital and Health Services participating. CONCLUSION: The uptake of the Imminent Birth Education Program has been widespread across the state and positively evaluated by the rural and remote non-midwifery workforce in non-birthing facilities. This evidence-based program is an effective way to provide the knowledge, skills and confidence to assist health professionals to care for women who present to these facilities when birth is imminent.

Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses.

BACKGROUND: Caesarean sections (CSs) are associated with increased maternal and perinatal morbidity, yet rates continue to increase within most countries. Effective interventions are required to reduce the number of non-medically indicated CSs and improve outcomes for women and infants. This paper reports findings of a systematic review of literature related to maternity service organisational interventions that have a primary intention of improving CS rates. METHOD: A three-phase search strategy was implemented to identify studies utilising organisational interventions to improve CS rates in maternity services. The database search (including Cochrane CENTRAL, CINAHL, MEDLINE, Maternity and Infant Care, EMBASE and SCOPUS) was restricted to peer-reviewed journal articles published from 1 January 1980 to 31 December 2017. Reference lists of relevant reviews and included studies were also searched. Primary outcomes were overall, planned, and unplanned CS rates. Secondary outcomes included a suite of birth outcomes. A series of meta-analyses were performed in RevMan, separated by type of organisational intervention and outcome of interest. Summary risk ratios with 95% confidence intervals were presented as the effect measure. Effect sizes were pooled using a random-effects model. RESULTS: Fifteen articles were included in the systematic review, nine of which were included in at least one meta-analysis. Results indicated that, compared with women allocated to usual care, women allocated to midwife-led models of care implemented across pregnancy, labour and birth, and the postnatal period were, on average, less likely to experience CS (overall) (average RR 0.83, 95% CI 0.73 to 0.96), planned CS (average RR 0.75, 95% CI 0.61 to 0.93), and episiotomy (average RR 0.84, 95% CI 0.74 to 0.95). Narratively, audit and feedback, and a hospital policy of mandatory second opinion for CS, were identified as interventions that have potential to reduce CS rates. CONCLUSION: Maternity service leaders should consider the adoption of midwife-led models of care across the maternity episode within their organisations, particularly for women classified as low-risk. Additional studies are required that utilise either audit and feedback, or a hospital policy of mandatory second opinion for CS, to facilitate the quantification of intervention effects within future reviews. PROSPERO REGISTRATION: CRD42016039458 ; prospectively registered.

Informing the development midwifery standards for practice: A literature review for policy development.

AIM: To critically appraise and synthesise the literature regarding the role and scope of midwifery practice, specifically to inform the evidence based development of standards for practice for all midwives in Australia. DESIGN: A structured scoping review of the literature DATA SOURCES: CINAHL Complete, MEDLINE Complete and Cochrane Libraries databases, online and grey literature databases REVIEW METHODS: Comprehensive searches of databases used key words and controlled vocabulary for each database to search for publications 2006-2016. Studies were not restricted by research method. FINDINGS: There is no substantive body of literature on midwifery competency standards or standards for practice. From 1648 papers screened, twenty-eight papers were identified to inform this review. Eight studies including systematic reviews were annotated with three research papers further assessed as having direct application to this review. To inform the development of Midwife standards for practice, the comprehensive role of the midwife across multiple settings was seen to include: woman centred and primary health care; safe supportive and collaborative practice; clinical knowledge and skills with interpersonal and cultural competence. KEY CONCLUSIONS: Midwifery practice is not restricted to the provision of direct clinical care and extends to any role where the midwife uses midwifery skills and knowledge. This practice includes working in clinical and non-clinical relationships with the woman and other clients as well as working in management, administration, education, research, advisory, regulatory, and policy development roles. IMPLICATIONS FOR PRACTICE: This review articulates the definition, role and scope of midwifery practice to inform the development of contemporary standards for practice for the Australian midwife.

An investigation of Australian midwifery curricula for obesity management and health behaviour change training.

INTRODUCTION: Fifty percent of Australian women enter pregnancy overweight or obese. Unfortunately, few women receive weight management advice from health professionals during pregnancy. The aim of this study was to investigate current midwifery curricula from Australian universities to identify strengths and deficits in the teaching of preconception and antenatal weight management. METHODS: Midwifery courses from 20 universities were identified. Of the 568 units taught at these universities, 252 course outlines were obtained. Data were coded using the qualitative analysis technique of Framework Analysis for the following main themes: 1) the effect of weight, diet and physical activity on health outcomes for women who are pregnant or planning a pregnancy; 2) weight management advice in any population; and 3) health behaviour change techniques in any context. RESULTS: Analysis revealed a variety of teaching methods and skills training that emphasised the importance of clinical judgement and autonomous clinical practice, in conjunction with critical enquiry and sourcing reputable evidence. There was little evidence, however, that weight management advice was taught explicitly to midwifery students in the curricula. DISCUSSION: A greater emphasis on skilling midwifery students to address weight gain during pregnancy, and behavioural techniques to achieve this, is required.

Association Between Prenatal Alcohol Exposure and Craniofacial Shape of Children at 12 Months of Age.

Importance: Children who receive a diagnosis of fetal alcohol spectrum disorder may have a characteristic facial appearance in addition to neurodevelopmental impairment. It is not well understood whether there is a gradient of facial characteristics of children who did not receive a diagnosis of fetal alcohol spectrum disorder but who were exposed to a range of common drinking patterns during pregnancy. Objective: To examine the association between dose, frequency, and timing of prenatal alcohol exposure and craniofacial phenotype in 12-month-old children. Design, Setting, and Participants: A prospective cohort study was performed from January 1, 2011, to December 30, 2014, among mothers recruited in the first trimester of pregnancy from low-risk, public maternity clinics in metropolitan Melbourne, Australia. A total of 415 white children were included in this analysis of 3-dimensional craniofacial images taken at 12 months of age. Analysis was performed with objective, holistic craniofacial phenotyping using dense surface models of the face and head. Partial least square regression models included covariates known to affect craniofacial shape. Exposures: Low, moderate to high, or binge-level alcohol exposure in the first trimester or throughout pregnancy. Main Outcomes and Measures: Anatomical differences in global and regional craniofacial shape between children of women who abstained from alcohol during pregnancy and children with varying levels of prenatal alcohol exposure. Results: Of the 415 children in the study (195 girls and 220 boys; mean [SD] age, 363.0 [8.3] days), a consistent association between craniofacial shape and prenatal alcohol exposure was observed at almost any level regardless of whether exposure occurred only in the first trimester or throughout pregnancy. Regions of difference were concentrated around the midface, nose, lips, and eyes. Directional visualization showed that these differences corresponded to general recession of the midface and superior displacement of the nose, especially the tip of the nose, indicating shortening of the nose and upturning of the nose tip. Differences were most pronounced between groups with no exposure and groups with low exposure in the first trimester (forehead), moderate to high exposure in the first trimester (eyes, midface, chin, and parietal region), and binge-level exposure in the first trimester (chin). Conclusions and Relevance: Prenatal alcohol exposure, even at low levels, can influence craniofacial development. Although the clinical significance of these findings is yet to be determined, they support the conclusion that for women who are or may become pregnant, avoiding alcohol is the safest option.

The Virtual Maternity Clinic: a teaching and learning innovation for midwifery education.

BACKGROUND: There are challenges for midwifery students in developing skill and competency due to limited placements in antenatal clinics. The Virtual Maternity Clinic, an online resource, was developed to support student learning in professional midwifery practice. OBJECTIVES: Identifying students' perceptions of the Virtual Maternity Clinic; learning about the impact of the Virtual Maternity Clinic on the students' experience of its use and access; and learning about the level of student satisfaction of the Virtual Maternity Clinic. DESIGN: Two interventions were used including pre and post evaluations of the online learning resource with data obtained from questionnaires using open ended and dichotomous responses and rating scales. The pre-Virtual Maternity Clinic intervention used a qualitative design and the post-Virtual Maternity Clinic intervention applied both qualitative and quantitative approaches. SETTINGS: Three campuses of Deakin University, located in Victoria, Australia. PARTICIPANTS: Midwifery students enrolled in the Bachelor of Nursing/Bachelor of Midwifery and Graduate Diploma of Midwifery were recruited across three campuses of Deakin University (n=140). METHODS: Thematic analysis of the pre-Virtual Maternity Clinic intervention (return rate n=119) related to students' expectations of this resource. The data for the post-Virtual Maternity Clinic intervention (return rate n=42) including open-ended responses were thematically analysed; dichotomous data examined in the form of frequencies and percentages of agreement and disagreement; and 5-rating scales were analysed using Pearson's correlations (α=.05, two-tailed). RESULTS: Results showed from the pre-Virtual Maternity Clinic intervention that students previously had placements in antenatal clinics were optimistic about the online learning resource. The post-Virtual Maternity Clinic intervention results indicated that students were satisfied with the Virtual Maternity Clinic as a learning resource despite some technological issues. CONCLUSIONS: The Virtual Maternity Clinic provides benefits for students in repeated observation of the practice of the midwife to support their professional learning and practice development.

Continuity of midwifery care and gestational weight gain in obese women: a randomised controlled trial.

BACKGROUND: The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women's experience of pregnancy care; women's satisfaction with care and a range of psychological factors. METHODS/DESIGN: A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI ≥ 30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include socio-demographic information and the use of validated scales to measure secondary outcomes. DISCUSSION: Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610001078044.

Putting woman-centered care into practice: a new (ANEW) approach to psychosocial risk assessment during pregnancy.

BACKGROUND: When antenatal care is provided, identification and management of challenging problems, such as depression, domestic violence, child abuse, and substance abuse, are absent from traditional midwifery and medical training. The main objective of this project was to provide an alternative to psychosocial risk screening in pregnancy by offering a training program (ANEW) in advanced communication skills and common psychosocial issues to midwives and doctors, with the aim of improving identification and support of women with psychosocial issues in pregnancy. METHODS: ANEW used a before-and-after survey design to evaluate the effects of a 6-month educational intervention for health professionals. The setting for the project was the Mercy Hospital for Women in Melbourne, Australia. Surveys covered issues, such as perceived competency and comfort in dealing with specific psychosocial issues, self-rated communication skills, and open-ended questions about participants' experience of the educational program. RESULTS: Educational program participants (n = 22/27) completed both surveys. After the educational intervention, participants were more likely to ask directly about domestic violence (p = 0.05), past sexual abuse (p = 0.05), and concerns about caring for the baby (p = 0.03). They were less likely to report that psychosocial issues made them feel overwhelmed (p = 0.01), and they reported significant gains in knowledge of psychosocial issues, and competence in dealing with them. Participants were highly positive about the experience of participating in the program. CONCLUSIONS: The program increased the self-reported comfort and competency of health professionals to identify and care for women with psychosocial issues.