Empowering nurses and midwives: the evidence-base for the Nurses and Midwives Certification Programme of ESHRE†.

STUDY QUESTION: How were the logbook and curriculum for the Nurses and Midwives Certification Programme of ESHRE developed? SUMMARY ANSWER: The logbook and corresponding curriculum for the ESHRE Nurses and Midwives Certification Programme were based on an extensive literature review, an international expert panel, and a survey of Belgian and Dutch nurses and midwives (N&M) working in reproductive medicine (RM). WHAT IS KNOWN ALREADY: ESHRE has been running a certification programme for N&M working in RM since 2015. To the best of our knowledge, clinical practice guidelines for nursing/midwifery care within RM are lacking as is consensus on role descriptors of N&M working in RM. STUDY DESIGN, SIZE, DURATION: The Nurses and Midwives Certification Committee (NMCC), established by the ESHRE Executive Committee in 2012, decided to gather background information by: (i) systematically reviewing the literature on the tasks of N&M working in RM, (ii) consulting and surveying an expert panel of international senior N&M, and (iii) surveying Belgian and Dutch N&M working in RM across different clinics. Finally, the NMCC developed a logbook and curriculum fostering a more expanded theoretic background. PARTICIPANTS/MATERIALS, SETTING, METHODS: The NMCC comprised four N&M, one clinical embryologist, and one gynaecologist (both in an advisory capacity). The Medline database was searched for papers relating to the tasks of N&M working in RM, by entering a search string in PubMed. In an attempt to capture insight into the tasks and roles of N&M working in RM, the NMCC subsequently surveyed N&M experts across nine countries (Denmark, Finland, France, Norway, Slovenia, Sweden, Turkey, Ukraine, and the UK), and 48 Belgian and Dutch N&M working in RM. MAIN RESULTS AND THE ROLE OF CHANCE: There were 36 papers on the tasks of N&M working in RM originating from 13 countries (in Asia, Oceania, Europe, and North America), identified. Initially, 43 tasks in which N&M working in RM participated, were identified by literature only (n = 5), the international expert panel only (n = 4), Belgian and Dutch N&M working in RM only (n = 5), or a combination of two (n = 13) or three (n = 16) of these sources. The number and composition of tasks included in the logbook were adapted yearly based on novel insights by the NMCC. In response to the annual review, the extended role of N&M working in RM is now reflected in the 2024 version by 73 tasks. Seven specialist tasks (i.e. embryo transfer) were performed independently by N&M working in RM in some countries, while in other countries N&M merely had an 'assisting' role. Candidates are also expected to submit a mature ethical reflection on one clinical case. To support applicants throughout the certification process, the NMCC developed a curriculum in line with all tasks of N&M working in RM. LIMITATIONS, REASONS FOR CAUTION: The literature review was not completed prior to consulting the international expert panel or surveying the Belgian and Dutch N&M working in RM. WIDER IMPLICATIONS OF THE FINDINGS: The differences in tasks and roles of N&M working in RM across and within countries, clinics and individuals illustrated by the literature review, the international expert panel, and the surveyed Belgian and Dutch N&M working in RM suggest an opportunity for structured professional development. Further research is required to elicit the post-certification experience of N&M working in RM and its impact on their professional development. STUDY FUNDING/COMPETING INTEREST(S): The expert panel meeting was funded by ESHRE and the literature review and surveys were supported by Leuven University (Belgium) and the postdoctoral fellowship of the Research Foundation Flanders of E.A.F.D. H.K. received consulting fees and honoraria from Gedeon Richter, Finox and MEDEA, and travel support from Gedeon Richter and Finox. The other authors declare no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model: A Sequential Explanatory Mixed-Methods Study.

BACKGROUND: In recent decades, medical supervision of the labor and delivery process has expanded beyond its boundaries to the extent that in many settings, childbirth has become a medical event. This situation has influenced midwifery care. One of the significant barriers to midwives providing care to pregnant women is the medicalization of childbirth. So far, the policies and programs of the Ministry of Health to reduce medical interventions and cesarean section rates have not been successful. Therefore, the current study aims to be conducted with the purpose of "Designing a Midwife-Led Birth Center Program Based on the MAP-IT Model". METHODS/DESIGN: The current study is a mixed-methods sequential explanatory design by using the MAP-IT model includes 5 steps: Mobilize, Assess, Plan, Implement, and Track, providing a framework for planning and evaluating public health interventions in a community. It will be implemented in three stages: The first phase of the research will be a cross-sectional descriptive study to determine the attitudes and preferences towards establishing a midwifery-led birthing center focusing on midwives and women of childbearing age by using two researcher-made questionnaires to assess the participants' attitudes and preferences toward establishing a midwifery-led birthing center. Subsequently, extreme cases will be selected based on the participants' average attitude scores toward establishing a midwifery-led birthing center in the quantitative section. In the second stage of the study, qualitative in-depth interviews will be conducted with the identified extreme cases from the first quantitative phase and other stakeholders (the first and second steps of the MAP-IT model, namely identifying and forming a stakeholder coalition, and assessing community resources and real needs). In this stage, the conventional qualitative content analysis approach will be used. Subsequently, based on the quantitative and qualitative data obtained up to this stage, a midwifery-led birthing center program based on the third step of the MAP-IT model, namely Plan, will be developed and validated using the Delphi method. DISCUSSION: This is the first study that uses a mixed-method approach for designing a midwife-led maternity care program based on the MAP-IT model. This study will fill the research gap in the field of improving midwife-led maternity care and designing a program based on the needs of a large group of pregnant mothers. We hope this program facilitates improved eligibility of midwifery to continue care to manage and improve their health easily and affordably. ETHICAL CODE: IR.MUMS.NURSE.REC. 1403. 014.

In recent decades, medical management of the labor and delivery process has extended beyond its limitations to the extent that in many settings, childbirth has become a medical event. This situation has influenced midwifery care. The global midwifery situation indicates that one in every five women worldwide gives birth without the support of a skilled attendant. One of the significant barriers to midwives providing care to pregnant women is the medicalization of childbirth. In industrialized countries, maternal and infant mortality rates have decreased over the past 60 years due to medical or social reasons. So far, the policies and programs of the Ministry of Health to diminish medical interventions and cesarean section rates have not been successful. Midwifery models in hospital care contain midwives who support women's choices and diverse ideas about childbirth on the one hand, and on the other hand, they must adhere to organizational guidelines as employees, primarily based on a medical and pathological approach rather than a health-oriented and midwifery perspective. Therefore, the current study aims to be conducted with the purpose of "Designing a midwifery-led birth centered maternity program based on the MAP-IT model". It is a Model for Implementing Healthy People 2030, (Mobilize, Assess, Plan, Implement, Track), a step-by-step method for creating healthy communities. Using MAP-IT can help public health professionals and community changemakers implement a plan that is tailored to a community's needs and assets.

Midwives' experience of respectful maternity care (RMC) globally: A meta-synthesis.

BACKGROUND: Respectful maternity care (RMC) emphasizes the social and relational elements of maternity care and is a crucial part of initiatives to improve service accessibility and quality. Women's perceptions have influenced much of what we know about RMC and contempt in the labor ward. In order to understand midwives' perspectives of RMC, this meta-synthesis focused on them. METHOD: For this inquiry, the databases PubMed/Medline, Embase, Web of Science, and Scopus were searched to find studies on midwives' perceptions of RMC written between 2011 and April 20th 2023. The included articles were to English language restriction. The results of the included research were examined using thematic analysis. Using the inclusion criteria, 84 potentially relevant articles were carefully reviewed, and only 22 were ultimately selected for synthesis. The quality of the qualitative study was assessed using the CASP, a tool for quality evaluation and PRISMA guidelines were followed. Using the MAXQDA program, the cited quotes and the original authors' interpretations were combined. RESULT: There were 22 studies total, thematic synthesis was determined to be appropriate for a total of 22 research studies. Following are the topics which we summarized our analysis: in six major themes: Midwives' conceptualizations of RMC, Midwives commitment to woman's rights, The value and impact of RMC to midwives, Midwife's perception of disrespectful care, Challenges in providing respectful maternity care, and Midwives' recommendations for optimal RMC practice. CONCLUSION: In addition to specific focus on promoting cooperation, policies to enhance health systems and strategic consideration of the midwifery profession's future are required.

National Nursing and Midwifery Commission Act, 2023 in India: Issues and the Way Forward.

With the recent enactment of the National Nursing and Midwifery Commission (NNMC) Act, 2023, significant changes are anticipated in the scope of practice and autonomy for registered nurses and midwives in India. However, alongside these anticipated advancements, concerns have emerged regarding various aspects of the Act, necessitating critical examination. In this article, we aim to explore expected changes in nursing education and service and concerns about the NNMC Act, providing insights into the implications of the NNMC Act on the regulation and advancement of the nursing and midwifery profession in India. The Act is anticipated to introduce uniform standards, implement entry and exit examinations, recognize midwifery as a distinct discipline, and determine the scope of practice for nurses and midwives. Moreover, the implementation of the Nurse Practitioner Program and guidelines for its limited prescribing authority is anticipated. Concerns exist regarding the composition of the commission and board members, adequate stakeholder representation, lacking provisions for ensuring continued competence, working conditions of nurses and midwives, nomenclature, integrating new terms, and clearly defining roles. These concerns emphasize the need for viable career pathways, uniform cadres, and a streamlined registration system, crucial for advancing nursing and midwifery profession in India. The coexistence of concerns and anticipation highlights the complexity of enacting regulatory reforms in nursing and midwifery. Policymakers can lay the foundation for a comprehensive, inclusive regulatory system that promotes excellence in nursing and midwifery practice, ultimately benefiting both healthcare providers and patients.

Strategies to improve the quality of midwifery care and developing midwife-centered care in Iran: analyzing the attitudes of midwifery experts.

BACKGROUND: In recent years, extensive studies have been designed and performed in the context of providing midwifery care in developed countries, which has been unfortunately neglected in some low resources and upper middle-income countries such as Iran. This study was conducted to identify the best strategies for improving the quality of midwifery care and developing midwife-centered care in Iran. METHODS: This was a qualitative study using focus group discussion and content analysis method. Data were collected from 121 participants including midwifery board members, gynecologists, heads of midwifery departments, midwifery students, in charge midwives in hospitals, and midwives in the private sector. Focused-group discussions were used for data collection, and data were analyzed using content analysis method. RESULTS: The main themes extracted from the participants' statements regarding improving the quality of midwifery care were as follows: Promotion and development of education, Manpower management, Rules, and regulations and standards for midwifery services, and Policy making. CONCLUSION: This study showed that to improve midwifery care, health policy makers should take into account both the quality and quantity of midwifery education, and promote midwifery human resources through employment. Furthermore, insurance support, encouragement, supporting and motivating midwives, enhancing and improving the facilities, providing hospitals and maternity wards with cutting-edge equipment, promoting and reinforcing the position of midwives in the family doctor program, and using a referral system were the strategies proposed by participants for improving midwifery care. Finally, establishing an efficient and powerful monitoring system to control the practice of gynecologists and midwives, promoting the collaborative practice of midwives and gynecologists, and encouraging team-work with respect to midwifery care were other strategies to improve the midwifery services in Iran. Authorities and policymakers may set the stage for developing high quality and affordable midwifery care by relying on the strategies presented in this study.

Do in-service training materials for midwifery care providers in sub-Saharan Africa meet international competency standards? A scoping review 2000-2020.

BACKGROUND: Levels of maternal and neonatal mortality remain high in sub-Saharan Africa, with an estimated 66% of global maternal deaths occurring in this region. Many deaths are linked to poor quality of care, which in turn has been linked to gaps in pre-service training programmes for midwifery care providers. In-service training packages have been developed and implemented across sub-Saharan Africa in an attempt to overcome the shortfalls in pre-service training. This scoping review has aimed to summarize in-service training materials used in sub-Saharan Africa for midwifery care providers between 2000 and 2020 and mapped their content to the International Confederation of Midwives (ICM) Essential Competencies for Midwifery Practice. METHODS: Searches were conducted for the years 2000-2020 in Cumulative Index of Nursing and Allied Health Literature, PubMed/MEDLINE, Social Science Citation Index, African Index Medicus and Google Scholar. A manual search of reference lists from identified studies and a search of grey literature from international organizations was also performed. Identified in-service training materials that were accessible freely on-line were mapped to the ICM Essential Competencies for midwifery practice. RESULTS: The database searches identified 1884 articles after removing duplicates. After applying exclusion criteria, 87 articles were identified for data extraction. During data extraction, a further 66 articles were excluded, leaving 21 articles to be included in the review. From these 21 articles, six different training materials were identified. The grey literature yielded 35 training materials, bringing the total number of in-service training materials that were reviewed to 41. Identified in-service training materials mainly focused on emergency obstetric care in a limited number of sub-Saharan Africa countries. Results also indicate that a significant number of in-service training materials are not readily and/or freely accessible. However, the content of in-service training materials largely met the ICM Essential Competencies, with gaps noted in the aspect of woman-centred care and shared decision making. CONCLUSION: To reduce maternal and newborn morbidity and mortality midwifery care providers should have access to evidence-based in-service training materials that include antenatal care and routine intrapartum care, and places women at the centre of their care as shared decision makers.

Implementation of evidence-based practice and associated factors among nurses and midwives working in Amhara Region government hospitals: a cross-sectional study.

BACKGROUND: Implementation of evidence-based practice is crucial to enhance quality health care, professional development, and cost-effective health service. However, many factors influence the implementation of evidence-based practice. Therefore, this study aimed to assess the implementation of evidence-based practice and associated factors among nurses and midwives. METHODS: Institutional-based cross-sectional study design was conducted to assess the implementation of evidence-based practice and associated factors from February 15 to March 15, 2019, among 790 nurses and midwives. Data were entered into EpiData version 3.1 then exported to SPSS version 20 for statistical analysis. Categorical variables were presented as frequency tables. Continuous variables were presented as descriptive measures, expressed as mean and standard deviation. Cronbach's alpha was used to measure reliability, mean, standard deviation, and inter-items correlation of the factors. Independent variables with a probability value (P-value) of less than 0.2 in the Chi-square analysis were entered in the multivariable logistic regression model. Statistically significant associated factors were identified at probability value (P-value) less than 0.05 and adjusted odds ratio with a 95% confidence interval. RESULTS: The mean age of participants was 28.35 (SD ± 4.5) years. This study revealed that 34.7% (95% CI 31.5-38%) of participants implemented evidence-based practice moderately or desirably. Age of participants (AOR = 5.98, CI 1.34-26.7), barriers of implementation of evidence-based practice (AOR = 4.8, CI 2.2-10.6), the attitude of participants (AOR = 5.02, CI 1.2-21.5), nursing/midwifery work index (AOR = 3.9, CI 1.4-10.87), self-efficacy of implementation of evidence-based practice skills (AOR = 12.5, CI 5.7-27.5) and knowledge of participants (AOR = 3.06, CI 1.6-5.77) were statistically significant associated factors of implementation of evidence-based practice CONCUSSION: Implementation of evidence-based practice of nurses and midwives was poor. Age of participants, barriers of implementation of evidence-based practice, the attitude of participants, self-efficacy of implementation of evidence-based practice skills, nursing/midwifery work index, and knowledge of participants were found to be predictors of implementation of evidence-based practice. Insufficient time and difficulty in judging the quality of research papers and reports were the most common barriers to the implementation of evidence-based practice.

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia-a cross-sectional study.

BACKGROUND: Delivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge. METHODS: Midwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores. RESULTS: Of 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that 'Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition. CONCLUSION: This study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Pregnancy and childbirth are natural phenomena, but sometimes have risk for mothers and babies. Therefore, childbirth should be carefully and continuously monitored by the health care professional. The 'partograph' is a useful tool that defines three monitoring aspects of the delivery progress, and conditions of the mother and intrauterine baby. However, it is often used inaccurately or inappropriately in low- and middle-income countries. We hypothesised that health professionals who assist childbirth cannot effectively monitor delivery conditions because their knowledge is insufficient. Therefore, we evaluated the knowledge on monitoring the process of childbirth and explored factors which affect the level of knowledge among health care providers in Cambodia.Midwives and nurses were targeted in this study who deal with normal deliveries in the capital city and two provinces. The questionnaire was designed to evaluate if their knowledge on three monitoring aspects is accurate.Of 542 eligible personnel, 523 (96%) participated. The mean score was 58%. Only 3% got scores of more than 90%. According to the statistical analysis, 'working in Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score.This study found that basic knowledge was low on delivery management among health care providers. We suspect that a deficiency of basic medical knowledge, such as physiology and anatomy, causes the lack of knowledge on the childbirth process. Further intervention should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Research utilisation in clinical practice: the experience of nurses and midwives working in public hospitals.

BACKGROUND: Nurses and midwives play a vital role to utilise research in clinical decision-making practice. However, limited support for research utilisation and barriers of research utilisation hamper to utilise up-to-date research findings in clinical practice. Therefore, this study aimed to explore nurses' and midwives' experience of research utilisation in public hospitals. METHODS: A qualitative descriptive approach was conducted to explore nurses' and midwives' experience of research utilisation in clinical practice within South Gondar Zone public hospitals from January 3 to June 28, 2020. A total of 20 interviewees, 40 participants of FGDs, and 8 observations were considered in the study. Data from the interview, FGD, and observation were imported into NVivo 12 plus to manage and analyze the data using the Computer-Assisted Data Analysis Software Program (CAQDAS). The data were analyzed through thematic content analysis. RESULTS: Nurses' and midwives' experience of using research findings in clinical decision-making emerged as "the non-intentional research utilisation" the main theme. Data analysis produced as "the belief towards research utilisation", "the limited support for nurses and midwives", and, "the perceived barriers of research utilisation" as the three themes. Participants believed that the non-use of the primary research was recommended due to fear of accountability for client harm. The limited support for nurses' and midwives' experience of research utilisation decrease nurses' and midwives' confidence to utilise research in clinical practice. Knowledge, attitude, time mismanagement, and the lack of motivation were perceived barriers to research utilisation. The lack of training and access to systematic review and meta-analysis research findings limited the research utilisation in clinical practice. CONCLUSIONS: The experience of research utilisation indicated that there was limited support for nurses and midwives to utilise research. Nurses and midwives did not utilise research in their clinical practice intentionally. This study identified that knowledge, negative attitude towards research utilisation, lack of training; time mismanagement, and lack of motivation were the perceived barriers to research utilisation. Therefore, the promotion of adopting the research utilisation and training on the identified barriers are mandatory. Nurses and midwives play a vital role to utilise research in clinical decision-making practice. However, the limited support for research utilisation and barriers of research utilisation hamper the utilisation of up-to-date research in clinical practice. Therefore, this study aimed to explore nurses' and midwives' experience of using the knowledge obtained from research findings in clinical and healthcare decision-making practice within public hospitals. The experience of research utilisation among nurses and midwives working in public hospitals was studied. There was limited support for nurses' and midwives' experience of research utilisation. Nurses and midwives did not utilise research in their clinical practice intentionally. The knowledge, negative attitude towards research utilisation, lack of training, time mismanagement, and lack of motivation were the perceived barriers to research utilisation. Therefore, the promotion of adopting the research utilisation and training on the identified barriers are mandatory.

Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: a mixed-method study protocol.

BACKGROUND: We aim to assess competencies (knowledge, skills and attitudes) of midwifery care providers as well as their experiences and perceptions of in-service training in the four study countries; Benin, Malawi, Tanzania and Uganda as part of the Action Leveraging Evidence to Reduce perinatal mortality and morbidity in sub-Saharan Africa project (ALERT). While today more women in low- and middle-income countries give birth in health care facilities, reductions in maternal and neonatal mortality have been less than expected. This paradox may be explained by the standard and quality of intrapartum care provision which depends on several factors such as health workforce capacity and the readiness of the health system as well as access to care. METHODS: Using an explanatory sequential mixed method design we will employ three methods (i) a survey will be conducted using self-administered questionnaires assessing knowledge, (ii) skills drills assessing basic intrapartum skills and attitudes, using an observation checklist and (iii) Focus Group Discussions (FGDs) to explore midwifery care providers' experiences and perceptions of in-service training. All midwifery care providers in the study facilities are eligible to participate in the study. For the skills drills a stratified sample of midwifery care providers will be selected in each hospital according to the number of providers and, professional titles and purposive sampling will be used for the FGDs. Descriptive summary statistics from the survey and skills drills will be presented by country. Conventional content analysis will be employed for data analysis of the FGDs. DISCUSSION: We envision comparative insight across hospitals and countries. The findings will be used to inform a targeted quality in-service training and quality improvement intervention related to provision of basic intrapartum care as part of the ALERT project. TRIAL REGISTRATION: PACTR202006793783148-June 17th, 2020.

Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Intrapartum-related perinatal deaths in births planned in midwifery-led settings in Great Britain: findings and recommendations from the ESMiE confidential enquiry.

OBJECTIVE: To review quality of care in births planned in midwifery-led settings, resulting in an intrapartum-related perinatal death. DESIGN: Confidential enquiry. SETTING: England, Scotland and Wales. SAMPLE: Intrapartum stillbirths and intrapartum-related neonatal deaths in births planned in alongside midwifery units, freestanding midwifery units or at home, sampled from national perinatal surveillance data for 2015/16 (alongside midwifery units) and 2013-16 (freestanding midwifery units and home births). METHODS: Multidisciplinary panels reviewed medical notes for each death, assessing and grading quality of care by consensus, with reference to national standards and guidance. Data were analysed using thematic analysis and descriptive statistics. RESULTS: Sixty-four deaths were reviewed, 30 stillbirths and 34 neonatal deaths. At the start of labour care, 23 women were planning birth in an alongside midwifery unit, 26 in a freestanding midwifery unit and 15 at home. In 75% of deaths, improvements in care were identified that may have made a difference to the outcome for the baby. Improvements in care were identified that may have made a difference to the mother's physical and psychological health and wellbeing in 75% of deaths. Issues with care were identified around risk assessment and decisions about planning place of birth, intermittent auscultation, transfer during labour, resuscitation and neonatal transfer, follow up and local review. CONCLUSIONS: These confidential enquiry findings do not address the overall safety of midwifery-led settings for healthy women with straightforward pregnancies, but suggest areas where the safety of care can be improved. Maternity services should review their care with respect to our recommendations. TWEETABLE ABSTRACT: Confidential enquiry of intrapartum-related baby deaths highlights areas where care in midwifery-led settings can be made even safer.

Reducing risks for pregnant women with epilepsy: A qualitative study exploring experiences of using a toolkit at the antenatal booking appointment.

PURPOSE: Epilepsy is a high risk neurological disease associated with an increased risk of indirect maternal mortality due to sudden unexpected death in epilepsy. No evidence exists on the antenatal booking risk management process in women with epilepsy. This study therefore aimed to explore the experiences of midwives' in using a maternity epilepsy toolkit designed by the author to assist with this process. Midwives were chosen as the sample as they are predominantly the first health professional to learn of the diagnosis at the antenatal booking appointment. OBJECTIVES: The objective of this study was to explore the experiences of midwives in using a maternity epilepsy toolkit at the booking appointment. DESIGN: This is a qualitative study using the principles of hermeneutic phenomenology. SETTING: The study setting is in One National Health Service (NHS) Trust in the South of England. PARTICIPANTS: The participants of the study were n = 4 community midwives who used the maternity epilepsy toolkit at the booking appointment. METHOD: In-depth semistructured one-to-one interviews were used. MEASUREMENTS: An interview schedule using main questions, probes, and reinforcers was implemented. Audio-recorded interviews were transcribed verbatim. Transcripts were checked against audio recordings for accuracy. ANALYSIS: Inductive approach organized by phenomenological framework to identify recurrent codes, patterns, and themes were used for analysis. FINDINGS: The following three themes clearly emerged: 'foundations of epilepsy knowledge', 'using the toolkit in midwifery practice', and 'the toolkits influence on learning'. CONCLUSION: Participants described lack of epilepsy knowledge and experience prior to using the 'toolkit' and how being prepared optimized its use. They articulated how it enabled them to collate the epilepsy and treatment history, share risk management strategies, and expedite referrals appropriately. They discussed how it increased confidence, reduced fear, and inspired motivation toward learning. The results of this study will provide a foundation for future research exploring the impact that the 'toolkit' has on multidisciplinary care provision. IMPLICATIONS FOR PRACTICE: This small study demonstrated the 'toolkits' potential as a method of increasing knowledge about epilepsy and risk management. Initiation of its use in early pregnancy is intended to promote effective history taking, facilitate the identification of women at increased risk of morbidity and mortality, and encourage joint working through early multidisciplinary team referral and involvement. This paper is for the Special Issue :Prevent 21: SUDEP Summit - Time to Listen.

The influence of quality and respectful care on the uptake of skilled birth attendance in Tanzania.

BACKGROUND: An increase in the uptake of skilled birth attendance is expected to reduce maternal mortality in low- and middle-income countries. In Tanzania, the proportion of deliveries assisted by a skilled birth attendant is only 64% and the maternal mortality ratio is still 398/100.000 live births. This article explores different aspects of quality of care and respectful care in relation to maternal healthcare. It then examines the influence of these aspects of care on the uptake of skilled birth attendance in Tanzania in order to offer recommendations on how to increase the skilled birth attendance rate. METHODS: This narrative review employed the "person-centered care framework for reproductive health equity" as outlined by Sudhinaraset (2017). Academic databases, search engines and websites were consulted, and snowball sampling was used. Full-text English articles from the last 10 years were included. RESULTS: Uptake of skilled birth attendance was influenced by different aspects of technical quality of maternal care as well as person-centred care, and these factors were interrelated. For example, disrespectful care was linked to factors which made the working circumstances of healthcare providers more difficult such as resource shortages, low levels of integrated care, inadequate referral systems, and bad management. These issues disproportionately affected rural facilities. However, disrespectful care could sometimes be attributed to personal attitudes and discrimination on the part of healthcare providers. Dissatisfied patients responded with either quiet acceptance of the circumstances, by delivering at home with a traditional birth attendant, or bypassing to other facilities. Best practices to increase respectful care show that multi-component interventions are needed on birth preparedness, attitude and infrastructure improvement, and birth companionship, with strong management and accountability at all levels. CONCLUSIONS: To further increase the uptake of skilled birth attendance, respectful care needs to be addressed within strategic plans. Multi-component interventions are required, with multi-stakeholder involvement. Participation of traditional birth attendants in counselling and referral can be considered. Future advances in information and communication technology might support improved quality of care.

Perception of childbirth experiences of Japanese women in Bali, Indonesia: a qualitative study.

BACKGROUND: Maternal healthcare services in Indonesia have seen dramatic improvements over the past 25 years and yet there is still room for improvement. The perception, by the women, of the perinatal care provided, is a vital input to further improving these services. This study examines how the perinatal care provided is experienced by Japanese women in Bali, using an interview survey. METHODS: We conducted semi-structured interviews, from August to October 2017, with 14 Japanese women living in Badung Regency and Denpasar City in Bali Province, Indonesia to report their perception of the perinatal care they experienced during their pregnancies. The interview guide included among others, the reasons for choosing specific (perinatal care) health facilities and their satisfaction with their experience of using the antenatal, delivery, and postnatal care services. The data were analysed using the qualitative content analysis method. RESULTS: From the interview data, 12 categories across five themes were extracted. Participants reported experiencing various concerns during their pregnancies such as difficulty in obtaining perinatal care related information. From the beginning of their pregnancies, participants gradually established trusting relationships with midwives, but in many situations, they were disappointed with their childbirth experiences, as they felt that the care provided was not woman-centred. Through their own efforts and with the support of family members and other Japanese residents, many women were able to eventually regard their childbirth experiences as positive. Nevertheless, some women could not overcome their negative impressions even years after childbirth. CONCLUSIONS: Participants desired close attention and encouragement from nurses and midwives. Our results suggest that Japanese women in Bali expected a woman-centred perinatal care and active support from nursing/midwifery staff during their pregnancies and postnatal care.

Midwives' engagement in smoking- and alcohol-prevention in prenatal care before and after the introduction of practice guidelines in Switzerland: comparison of survey findings from 2008 and 2018.

BACKGROUND: Evidence suggests that cigarette smoking and alcohol consumption during pregnancy negatively impacts fetal health. Health agencies across countries have developed specific guidelines for health professionals in perinatal care to strengthen their role in smoking and alcohol use prevention. One such example is the "Guideline on Screening and Counselling for prevention of cigarette smoking and alcohol consumption before, during, and after pregnancy" introduced by the Swiss Midwives Association in 2011. The current study assesses the changes in midwives' engagement in smoking and alcohol use prevention before (2008) and after the introduction of the Guideline (2018). Further, the current study examines differences across regions (German vs. French speaking regions), graduation years (before and after the introduction of the Guideline) and different work settings (hospital vs. self-employed). METHODS: Survey data were collected in 2008 (n = 366) and in 2018 (n = 459). Differences in how midwives engaged in smoking and alcohol use prevention between 2008 and 2018 were assessed with chi-square tests, as were differences across German and French speaking regions, graduation years (before and after the introduction of the Guideline) and across different work settings (working in hospitals or as self-employed). RESULTS: An increase in midwives' awareness of the risks of consuming even small quantities of cigarettes and alcohol for the unborn child between 2008 and 2018 is evident. Explaining the risks to pregnant women who smoke or use alcohol remained the most frequently reported prevention strategy. However, engagement with more extensive smoking and alcohol use preventive strategies across the whole course of pregnancy, such as assisting women in the elaboration of a plan to stop smoking/alcohol use, remained limited. CONCLUSIONS: Seven years after its introduction, the effectiveness of the Guideline in increasing midwives' engagement in smoking and alcohol use prevention appears limited despite midwives' increased awareness.

Competencies for respectful maternity care: Identifying those most important to midwives worldwide.

BACKGROUND: A respectful, person-centered philosophy of maternity care has been emerging over several decades. Research conducted on behalf of the International Confederation of Midwives (ICM) to identify essential competencies for midwifery practice also identified the knowledge, skills, and professional behaviors that should be hallmarks of respectful maternity care practices among the global community of midwives. METHODS: A three-round, online, modified Delphi survey was conducted between April 2016 and October 2016. A total of 895 individuals from 90 of the then-current 105 ICM member countries participated, with good representation across English, French, and Spanish speakers, high-income, medium-income, and low-income countries, and educators and clinicians. RESULTS: A total of 115 respectful maternity care (RMC)-related items were endorsed by participants in Round 1 or 2. These items received average scores of between 90.24% and 99.10%, well above the 85% threshold required to be identified as within the scope of global midwifery practice. These items were compared with the 12 domains of RMC identified by Shakibazadeh and colleagues that defined respectful care during childbirth in health facilities globally, and with similar RMC frameworks, and were found to be highly congruent, thus demonstrating the high value of RMC within the core of midwifery practice. DISCUSSION: ICM survey items were endorsed across all 12 RMC domains proposed by Shakibazadeh et al, and the findings affirmed that across ICM countries and regions, the philosophy of RMC was integrally related to the knowledge, skills, and professional behaviors that emerged as essential for basic midwifery practice.

Factors affecting third-stage management and postpartum hemorrhage in planned midwife-led home and birth center births in the United States.

BACKGROUND: Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery. METHODS: Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice. RESULTS: Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38). CONCLUSIONS: Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.

Systematic review of barriers to, and facilitators of, the provision of high-quality midwifery services in India.

BACKGROUND: The Indian government has committed to implementing high-quality midwifery care to achieve universal health coverage and reduce the burden of maternal and perinatal mortality and morbidity. There are multiple challenges, including introducing a new cadre of midwives educated to international standards and integrating midwifery into the health system with a defined scope of practice. The objective of this review was to examine the facilitators and barriers to providing high-quality midwifery care in India. METHODS: We searched 15 databases for studies relevant to the provision of midwifery care in India. The findings were mapped to two global quality frameworks to identify barriers and facilitators to providing high-quality midwifery care in India. RESULTS: Thirty-two studies were included. Key barriers were lack of competence of maternity care providers, lack of legislation recognizing midwives as autonomous professionals and limited scope of practice, social and economic barriers to women accessing services, and lack of basic health system infrastructure. Facilitators included providing more hands-on experience during training, monitoring and supervision of staff, utilizing midwives to their full scope of practice with good referral systems, improving women's experiences of maternity care, and improving health system infrastructure. CONCLUSIONS: The findings can be used to inform policy and practice. Overcoming the identified barriers will be critical to achieving the Government of India's plans to reduce maternal and neonatal mortality through the introduction of a new cadre of midwives. This is unlikely to be effective until the facilitators described are in place.

Process lessons from evaluating a combined continuity of carer and home birth scheme.

INTRODUCTION: Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period. METHODS: Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets. RESULTS: Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women's changing circumstances, and data recording lapses were complicating issues. CONCLUSIONS: Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme's viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.