Midwife-led birthing centres in four countries: a case study.

BACKGROUND: Midwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC. METHODS: A descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff. RESULTS: Key enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels. CONCLUSION: The findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Woman and girl-centred care for those affected by female genital mutilation: a scoping review of provider tools and guidelines.

BACKGROUND: A woman and girl centred, rights-based approach to health care is critical to achieving sexual and reproductive health. However, women with female genital mutilation in high-income countries have been found to receive sub-optimal care. This study examined documents guiding clinicians in health and community service settings in English-speaking high-income countries to identify approaches to ensure quality women and girl-centred care for those with or at risk of female genital mutilation. METHOD: We undertook a scoping review using the integrative model of patient-centredness to identify principles, enablers, and activities to facilitate woman and girl-centred care interactions. We developed an inclusion criterion to identify documents such as guidance statements and tools and technical guidelines, procedural documents and clinical practice guidelines. We searched the databases and websites of health professional associations, ministries of health, hospitals, national, state and local government and non-government organisations working in female genital mutilation in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation tool was used to appraise screened documents. FINDINGS: One-hundred and twenty-four documents were included in this scoping review; 88 were developed in the United Kingdom, 20 in Australia, nine in the United States, three in Canada, two in New Zealand and two in Ireland. The focus of documents from the United Kingdom on multi-professional safeguarding (62), while those retrieved from Australia, Canada, Ireland, New Zealand and the US focused on clinical practice. Twelve percent of the included documents contained references to all principles of patient-centred care, and only one document spoke to all principles, enablers and activities. CONCLUSION: This study demonstrates the need to improve the female genital mutilation-related guidance provided to professionals to care for and protect women and girls. Professionals need to involve women and girls with or at risk of female genital mutilation in the co-design of guidelines and tools and evaluation of them and the co-production of health care.

High-quality health care for women and girls should be provided by health workers who are respectful and caring. Health workers should also work with others as a team and help women and girls make their own decisions about their health care. This approach is called patient-centred care. Female genital mutilation (FGM) is a cultural practice associated with poor health outcomes. Women who have experienced FGM have not always received quality health care. We studied the guidance and tools to help health workers provide care to women and girls with or at risk of FGM. This study aimed to understand how health workers are supported to provide woman and girl-centred health care in these documents. We searched for these documents on the websites of health professional associations, government health departments and organisations working in FGM in the United Kingdom, Ireland, Canada, The United States, New Zealand, and Australia. The documents were analysed using a tool that described all the important areas needed to provide patient-centred health care. Of the 124 documents, we found that only 12% contained information about all aspects of patient-centred care. Only one document had details about all the areas that are part of patient-centred care. This study shows that we need to improve the FGM-related guidance provided to health workers to care for and protect women and girls. There is a need for health workers to involve women and girls with or at risk of FGM in designing guidelines and tools and evaluating them to these documents best fit their needs.

Maternity care experiences and health needs of migrant women from female genital mutilation-practicing countries in high-income contexts: A systematic review and meta-synthesis.

BACKGROUND: Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM. METHODS: We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers. RESULTS: Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care. CONCLUSIONS: The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented.

Evidence-based policy responses to strengthen health, community and legislative systems that care for women in Australia with female genital mutilation / cutting.

BACKGROUND: The physical and psychological impact of female genital mutilation / cutting (FGM/C) can be substantial, long term, and irreversible. Parts of the health sector in Australia have developed guidelines in the management of FGM/C, but large gaps exist in community and professional knowledge of the consequences and treatment of FGM/C. The prevalence of FGM/C amongst Australian women is unknown. Our article reviews the literature on research on FGM/C in Australia, which focuses on health system response to women and girls with FGM/C. Recommendations are made for policy reform in health, legislation, and community programs to provide the best healthcare, protect children, and help communities abandon this harmful practice. MAIN BODY: Midwives and doctors in Australia acknowledged a lack of knowledge on FGM/C, clinical guidelines and consequences for maternity care. In a metropolitan Australian hospital with specialised FGM/C care, women with FGM/C had similar obstetric outcomes as women without FGM/C, underlining the importance of holistic FGM/C clinics. Greater focus on integration of refugee and migrant populations into their new cultures may be an important way of facilitating the abandonment of this practice, as is education of communities that practise FGM/C, and experts involved in the care and protection of children. Men could be important advocates for protecting women and girls from violence and FGM/C through a man-to-man strategy with programs focussing on men's health and other personal issues, education, and communication. The Australian Government has identified gender-based violence as an area of priority and has been implementing a National plan to reduce violence against women and their children 2010-2022. A multidisciplinary network of experts on FGM/C could be established within this taskforce to develop well-defined and rapid referral pathways to care for and protect these children, as well as coordinate education and prevention programs to help communities abandon this harmful practice. CONCLUSION: Countries of migration can be part of the solution for abandonment of FGM/C through community interventions and implementation of national and coordinated training in FGM/C of experts involved in the care and protection of children and women. The global focus on collaboration on research, training and prevention programs should be fostered between countries of FGM/C prevalence and migration.

Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study.

BACKGROUND: Women, who have been subjected to female genital mutilation (FGM), can suffer serious and irreversible physical, psychological and psychosexual complications. They have more adverse obstetric outcomes as compared to women without FGM. Exploratory studies suggest radical change to abandonment of FGM by communities after migration to countries where FGM is not prevalent. Women who had been subjected to FGM as a child in their countries of origin, require specialised healthcare to reduce complications and further suffering. Our study compared obstetric outcomes in women with FGM to women without FGM who gave birth in a metropolitan Australian hospital with expertise in holistic FGM management. METHODS: The obstetric outcomes of one hundred and ninety-six women with FGM who gave birth between 2006 and 2012 at a metropolitan Australian hospital were analysed. Comparison was made with 8852 women without FGM who gave birth during the same time period. Data were extracted from a database specifically designed for women with FGM and managed by midwives specialised in care of these women, and a routine obstetric database, ObstetriX. The accuracy of data collection on FGM was determined by comparing these two databases. All women with FGM type 3 were deinfibulated antenatally or during labour. The outcome measures were (1) maternal: accuracy and grade of FGM classification, caesarean section, instrumental birth, episiotomy, genital tract trauma, postpartum blood loss of more than 500 ml; and (2) neonatal: low birth weight, admission to a special care nursery, stillbirth. RESULTS: The prevalence of FGM in women who gave birth at the metropolitan hospital was 2 to 3 %. Women with FGM had similar obstetric outcomes to women without FGM, except for statistically significant higher risk of first and second degree perineal tears, and caesarean section. However, none of the caesarean sections were performed for FGM indications. The ObstetriX database was only 35 % accurate in recording the correct FGM type. CONCLUSION: Women with FGM had similar obstetric outcomes to women without FGM in an Australian metropolitan hospital with expertise in FGM management. Specialised FGM services with clinical practice guideline and education of healthcare professionals may increase the detection rate of FGM and improve obstetric management of women with FGM.

Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.

This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.

The role of men in abandonment of female genital mutilation: a systematic review.

BACKGROUND: Men in their roles as fathers, husbands, community and religious leaders may play a pivotal part in the continuation of female genital mutilation (FGM). However, the research on their views of FGM and their potential role in its abandonment are not well described. METHODS: We undertook a systematic review of all publications between 2004 and 2014 that explored men's attitudes, beliefs, and behaviours in regards to FGM, as well as their ideas about FGM prevention and abandonment. RESULTS: We included twenty peer-reviewed articles from 15 countries in the analysis. Analysis revealed ambiguity of men's wishes in regards to the continuation of FGM. Many men wished to abandon this practice because of the physical and psychosexual complications to both women and men. Social obligation and the silent culture between the sexes were posited as major obstacles for change. Support for abandonment was influenced by notions of social obligation, religion, education, ethnicity, urban living, migration, and understanding of the negative sequelae of FGM. The strongest influence was education. CONCLUSION: The level of education of men was one of the most important indicators for men's support for abandonment of FGM. Social obligation and the lack of dialogue between men and women were two key issues that men acknowledged as barriers to abandonment. Advocacy by men and collaboration between men and women's health and community programs may be important steps forward in the abandonment process.

Strengthening woman-centred care for pregnant women with female genital mutilation in Australia: a qualitative muti-method study.

Woman-centred care is a collaborative approach to care management, where the woman and her health provider recognise one another's expertise and interact based on mutual respect to provide adequate information and individualised care. However, woman-centred care has not been fully achieved, particularly for women who have experienced female genital mutilation in high-income countries. A lack of clear guidelines defining how to implement woman-centred care may negatively impact care provision. This study sought to explore the quality of point-of-care experiences and needs of pregnant women with female genital mutilation in Australia to identify elements of woman-centred care important to women and how woman-centred care can be strengthened during consultations with health professionals. This multi-method qualitative study comprised two phases. In phase one, we conducted interviews with women with female genital mutilation to explore their positive experiences during their last pregnancy, and in phase two, a workshop was held where the findings were presented and discussed to develop recommendations for guidelines to support woman-centred care. The findings of the first phase were presented under three distinct categories of principles, enablers, and activities following a framework from the literature. In phase two, narrative storytelling allowed women to share their stories of care, their preferences, and how they believe health providers could better support them. Their stories were recorded visually. This study highlights the importance of a comprehensive approach to woman-centred care involving experts, clinicians, community members, and women in designing education, tools, and guidelines.

Women's experiences of receiving antenatal and intrapartum care during COVID-19 at public hospitals in the Sidama region, Ethiopia: A qualitative study using the combination of three delay and social-ecological framework (hybrid framework).

BACKGROUND: The COVID-19 pandemic, drought and internal conflict have worsened Ethiopia's already weak healthcare system. Antenatal and intrapartum care are especially prone to interruption under these circumstances. OBJECTIVE: To explore women's experiences receiving antenatal and intrapartum care during the pandemic. DESIGN: A descriptive qualitative approach was utilised. METHODS: We conducted in-depth interviews with 17 women and held 4 focus group discussions with women who gave birth at 4 public hospitals during the pandemic. A study was conducted at four public hospitals in the Sidama region of Ethiopia, during which data were collected from 14 February to 10 May 2022. Thematic analysis was performed to generate themes. RESULTS: The peak of the COVID-19 pandemic in Ethiopia presented several barriers to access and uptake of antenatal and intrapartum care at public hospitals. Four themes and 10 subthemes emerged from the thematic analysis. The themes were 'Barriers to maternity care uptake during COVID-19', 'Shortage of resources during COVID-19', 'Delays in maternity care uptake during COVID-19' and 'Mistreatment of women during maternity care during COVID-19'. The subthemes included 'Fear of contracting COVID-19', 'People in the hospital neglecting COVID-19 prevention', 'Women losing their job during COVID-19', 'Shortage of beds in the labour ward', 'Shortage of medical supplies', 'Delays in seeking care', 'Delays in receiving care', 'Complications during childbirth', 'disrespectful' and 'suboptimal care'. CONCLUSION: The findings of this study underscore the impact of COVID-19 on antenatal and intrapartum care, leading to delays in seeking and receiving care due to reduced rapport, resource shortages, companion restrictions, disrespectful care and suboptimal care. These factors contribute to increased obstetric complications during COVID-19. It is imperative for policymakers to prioritise essential resources for antenatal and intrapartum care in the present and future pandemics. Moreover, healthcare providers should maintain respectful and optimal care even amid challenges.

Women's experiences in receiving antenatal and intrapartum care during COVID-19The COVID-19 pandemic has posed a significant challenge in seeking and receiving care of antenatal care and institutional childbirth. Women could experience delays in booking antenatal care appointments, postponing antenatal care visits, and facing delays in receiving care at hospitals, which has disrupted their access to routine antenatal care and institutional birth during the pandemic. This study highlights a range of barriers that hinder access to and utilisation of antenatal care and institutional birth, including lack of transport, shortage of resources, fear of contracting the virus, companion restrictions, disrespectful care and suboptimal care that leads to increased obstetric complications during COVID-19. This study provides recommendations for policymakers to prioritise resources and enhance respectful and optimal care for pregnancy and institutional birth to lessen the indirect impact of present and future pandemics on pregnant women and their unborn babies.

Impact of COVID-19 on antenatal care provision at public hospitals in the Sidama region, Ethiopia: A mixed methods study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) continues to pose a global public health threat. The pandemic overstretched already weak health systems in low- and low-middle-income countries, including Ethiopia. There is a paucity of studies on the impact of COVID-19 on antenatal care access, uptake, and provision in Ethiopia. This study examines the impact of COVID-19 on antenatal care provision in the Sidama region, Ethiopia. METHODS: A concurrent mixed-methods study was conducted between 14 February and 10 May 2022 at 15 public hospitals in the Sidama region. An interrupted times series design was applied for a quantitative study, which included data from all pregnant women who attended antenatal care before COVID-19 (12 months, March 2019 to February 2020) and during COVID-19 (six months, March to August 2020) at 15 public hospitals in the region. The total numbers in the antenatal care 1 cohort (at least one antenatal care contact) and antenatal care 4 cohort (at least four antenatal care contacts) were 15,150 and 5,850, respectively, forming a combined final dataset of 21,000 women. Routinely collected monthly data were derived from the hospitals' health management information system and imported into Stata version 17 for analysis. The mean monthly incidence rate ratio of antenatal care uptake was calculated using a Poisson regression model with a 95% confidence interval. Simultaneously, an exploratory study design was conducted for qualitative using in-depth interviews to explore maternity care providers' perceptions of the impact of COVID-19 on antenatal care access, uptake, and provision. Qualitative data were thematically analysed. The quantitative and qualitative findings were then integrated using the joint display technique. RESULTS: Our findings indicate a significant monthly decrease of 0.7% in antenatal care 1 and 1.8% in antenatal care 4 during the first six months of the pandemic. A lack of medical supplies, fear of contracting COVID-19, inadequate personal protective equipment, discrimination against those attending the hospital, and the absence of antenatal care guidelines for care provision, COVID-19 vaccine hesitancy and long waiting times for ANC led to disrupted access, uptake, and provision of antenatal care during COVID-19. CONCLUSION AND RECOMMENDATIONS: Our findings demonstrate that the COVID-19 pandemic affected antenatal care access, uptake, and provision in the study area from March to August 2020. To mitigate disrupted antenatal care access, uptake and provision, antenatal care clinics should be equipped with medical supplies. It is crucial to maintain rapport between the community and maternity care providers and provide training for maternity care providers regarding the adapted/adopted guidelines during COVID-19 at the hospital grassroots level for use in the current and future pandemics. Pregnant women should have timely access to maternity care providers in order to maintain at least a minimum standard of care in current and future pandemics.

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review.

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

Perceptions of quality of care in Midwife-led Birth Centres (MLBCs) in Uganda: Why do women choose MLBCs over other options?

BACKGROUND: Midwife-led birth centres (MLBCs) are associated with reduced childbirth interventions, higher satisfaction rates, and improved birth outcomes. The evidence on quality of care in MLBCs from low and middle-income countries (LMIC) is limited. AIM: This study aimed to explore the perceptions of women and midwives regarding the quality of care in four MLBCs in Uganda. METHODS: A qualitative study was conducted in four MLBCs in Uganda. We conducted interviews with women and midwives in the MLBCs to explore their perceptions and experiences related to care in the MLBCs. The study obtained ethical approval. Deductive thematic analysis was used for data analysis. RESULTS: Three key themes were identified regarding the perceptions of women and midwives about the quality of care in the MLBCs: providing respectful, and dignified care; a focus on woman-centred care; and reasons for choosing care in the MLBC. Women valued the respectful and humane care characterised by dignified and non-discriminatory care, non-abandonment, privacy, and consented care. The woman-centred care in the MLBC involved individualised holistic care, providing autonomy and empowerment, continuity of care, promoting positive birth experience, confidence in the woman's own abilities, and responsive providers. Women chose MLBCs because the services were perceived to be available, accessible, affordable, with comprehensive and effective referral mechanisms. CONCLUSION: Women perceived care to be respectful, woman-centred, and of good quality. Global attention should be directed to scaling up the establishment of MLBCs, especially in LMIC, to improve the positive childbirth experience and increase access to care.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites.

INTRODUCTION: Achieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative to hospital-based care for low-risk pregnancies where the lead professional at the time of birth is a trained midwife. These have been used in many countries to improve birth outcomes. METHODS: The cost analysis used primary data collection from four MLBCs in Bangladesh, Pakistan and Uganda (n=12 MLBC sites). Modelled cost-effectiveness analysis was conducted to compare the incremental cost-effectiveness ratio (ICER), measured as incremental cost per disability-adjusted life-year (DALY) averted, of MLBCs to standard care in each country. Results were presented in 2022 US dollars. RESULTS: Cost per birth in MLBCs varied greatly within and between countries, from US$21 per birth at site 3, Bangladesh to US$2374 at site 2, Uganda. Midwife salary and facility operation costs were the primary drivers of costs in most MLBCs. Six of the 12 MLBCs produced better health outcomes at a lower cost (dominated) compared with standard care; and three produced better health outcomes at a higher cost compared with standard care, with ICERs ranging from US$571/DALY averted to US$55 942/DALY averted. CONCLUSION: MLBCs appear to be able to produce better health outcomes at lower cost or be highly cost-effective compared with standard care. Costs do vary across sites and settings, and so further exploration of costs and cost-effectiveness as a part of implementation and establishment activities should be a priority.

Which low- and middle-income countries have midwife-led birthing centres and what are the main characteristics of these centres? A scoping review and scoping survey.

Evidence about the safety and benefits of midwife-led care during childbirth has led to midwife-led settings being recommended for women with uncomplicated pregnancies. However, most of the research on this topic comes from high-income countries. Relatively little is known about the availability and characteristics of midwife-led birthing centres in low- and middle-income countries (LMICs). This study aimed to identify which LMICs have midwife-led birthing centres, and their main characteristics. The study was conducted in two parts: a scoping review of peer-reviewed and grey literature, and a scoping survey of professional midwives' associations and United Nations Population Fund country offices. We used nine academic databases and the Google search engine, to locate literature describing birthing centres in LMICs in which midwives or nurse-midwives were the lead care providers. The review included 101 items published between January 2012 and February 2022. The survey consisted of a structured online questionnaire, and responses were received from 77 of the world's 137 low- and middle-income countries. We found at least one piece of evidence indicating that midwife-led birthing centres existed in 57 low- and middle-income countries. The evidence was relatively strong for 24 of these countries, i.e. there was evidence from at least two of the three types of source (peer-reviewed literature, grey literature, and survey). Only 14 of them featured in the peer-reviewed literature. Low- and lower-middle-income countries were more likely than upper-middle-income countries to have midwife-led birthing centres. The most common type of midwife-led birthing centre was freestanding. Public-sector midwife-led birthing centres were more common in middle-income than in low-income countries. Some were staffed entirely by midwives and some by a multidisciplinary team. We identified challenges to the midwifery philosophy of care and to effective referral systems. The peer-reviewed literature does not provide a comprehensive picture of the locations and characteristics of midwife-led birthing centres in low- and middle-income countries. Many of our findings echo those from high-income countries, but some appear to be specific to some or all low- and middle-income countries. The study highlights knowledge gaps, including a lack of evidence about the impact and costs of midwife-led birthing centres in low- and middle-income countries.

Exploring networks of care in implementing midwife-led birthing centres in low- and middle-income countries: A scoping review.

The evidence for the benefits of midwifery has grown over the past two decades and midwife-led birthing centres have been established in many countries. Midwife-led care can only make a sustained and large-scale contribution to improved maternal and newborn health outcomes if it is an integral part of the health care system but there are challenges to the establishment and operation of midwife-led birthing centres. A network of care (NOC) is a way of understanding the connections within a catchment area or region to ensure that service provision is effective and efficient. This review aims to evaluate whether a NOC framework-in light of the literature about midwife-led birthing centres-can be used to map the challenges, barriers and enablers with a focus on low-to-middle income countries. We searched nine academic databases and located 40 relevant studies published between January 2012 and February 2022. Information about the enablers and challenges to midwife-led birthing centres was mapped and analysed against a NOC framework. The analysis was based on the four domains of the NOC: 1) agreement and enabling environment, 2) operational standards, 3) quality, efficiency, and responsibility, 4) learning and adaptation, which together are thought to reflect the characteristics of an effective NOC.Of the 40 studies, half (n = 20) were from Brazil and South Africa. The others covered an additional 10 countries. The analysis showed that midwife-led birthing centres can provide high-quality care when the following NOC elements are in place: a positive policy environment, purposeful arrangements which ensure services are responsive to users' needs, an effective referral system to enable collaboration across different levels of health service and a competent workforce committed to a midwifery philosophy of care. Challenges to an effective NOC include lack of supportive policies, leadership, inter-facility and interprofessional collaboration and insufficient financing. The NOC framework can be a useful approach to identify the key areas of collaboration required for effective consultation and referral, to address the specific local needs of women and their families and identify areas for improvement in health services. The NOC framework could be used in the design and implementation of new midwife-led birthing centres.

An evaluation of the introduction of telehealth for remote antenatal and postnatal contacts in Bangladesh and Lao People's Democratic Republic during the COVID-19 pandemic.

From 2020, COVID-19 spread rapidly around the globe and continues to have a major impact on health system functioning, with a disproportionate impact on low- and middle-income countries (LMIC). Reduced service utilisation and coverage of essential childbirth interventions is likely impacting maternal and newborn morbidity and mortality. Telehealth has been identified as an important tool in the continued provision of essential healthcare services. The aim of this study was to explore the experience and impact of implementing telehealth services for the provision of remote antenatal (ANC) and postnatal (PNC) contacts in regions of Bangladesh and Lao People's Democratic Republic through 100 semi-structured interviews with health service leaders and providers, and childbearing women who organised, provided, or were the recipients of ANC and PNC telehealth during the COVID-19 pandemic response. The findings showed that a sudden pivot from face-to-face to telehealth services posed both health system and provision of care challenges. Health systems lacked funding to support telehealth and the infrastructure needed for service changes; however, some were able to work with key maternal child health departments within Ministries of Health to find the resources to implement the services. Health providers found telehealth beneficial during the pandemic response but identified a lack of training, guidance, and support as a barrier to changing practice. Childbearing women reported being fearful of accessing care at health services due to COVID-19, and whilst they appreciated the telehealth contacts, many continued to prefer face-to-face delivery of ANC and PNC care. Telehealth, however, was a good alternative in a time when face-to-face care was not possible. Considerations for post-pandemic broader implementation or scale-up of telehealth for routine antenatal and postnatal maternity care provision include the need for further research on issues such as accessibility, acceptability, quality of care, and sustainability of service provision.

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review.

BACKGROUND: All women require access to quality maternity care. Continuity of midwifery care can enhance women's experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities. AIM: To explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia. METHODS: This integrative review used Whittemore and Knafl's approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools. FINDINGS: Fourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: 'Contributing to safe processes and outcomes', 'Building relational trust', and 'Collaborating and communicating'. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women. DISCUSSION: The nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice. CONCLUSION: Despite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.

Reducing educational disparities between Australian adolescents in regional and metropolitan communities: The compensatory effects of extracurricular activities.

Australian adolescents living in regional communities are significantly more likely to perform worse at school, relative to those in metropolitan communities. These disparities are partially due to the development of lower educational expectations among regional adolescents. In the current study, we tested whether the differences in educational expectations across communities were reduced when adolescents engage in extracurricular activities, and any subsequent downstream effects on academic outcomes. The current study used a subsample of 1,477 adolescents recruited as part of the Longitudinal Study of Australian Children who have graduated from high school. Using a random-intercept cross-lagged panel model, we found that residing in a regional community at the start of secondary education predicted worse academic performance when graduating 6 years later. This association was partially mediated by lower educational expectations and school functioning, measured biennially. However, the significant difference between adolescents in metropolitan and regional communities dissipated when participants engaged in three or more types of extracurricular activities. These results highlight that increasing access and support to participate in extracurricular activities in regional communities may contribute to reducing inequities in educational outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments.

INTRODUCTION: Women and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives. METHODS: A structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020. RESULTS: In total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning. CONCLUSION: More efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings. PROSPERO REGISTRATION NUMBER: CRD42021226323.

Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial.

PROBLEM AND BACKGROUND: Caesarean section (CS) rates in Australia and many countries worldwide are high and increasing, with elective repeat caesarean section a significant contributor. AIM: To determine whether midwifery continuity of care for women with a previous CS increases the proportion of women who plan to attempt a vaginal birth in their current pregnancy. METHODS: A randomised controlled design was undertaken. Women who met the inclusion criteria were randomised to one of two groups; the Community Midwifery Program (CMP) (continuity across the full spectrum - antenatal, intrapartum and postpartum) (n=110) and the Midwifery Antenatal Care (MAC) Program (antenatal continuity of care) (n=111) using a remote randomisation service. Analysis was undertaken on an intention to treat basis. The primary outcome measure was the rate of attempted vaginal birth after caesarean section and secondary outcomes included composite measures of maternal and neonatal wellbeing. FINDINGS: The model of care did not significantly impact planned vaginal birth at 36 weeks (CMP 66.7% vs MAC 57.3%) or success rate (CMP 27.8% vs MAC 32.7%). The rate of maternal and neonatal complications was similar between the groups. CONCLUSION: Model of care did not significantly impact the proportion of women attempting VBAC in this study. The similarity in the number of midwives seen antenatally and during labour and birth suggests that these models of care had more similarities than differences and that the model of continuity could be described as informational continuity. Future research should focus on the impact of relationship based continuity of care.