[Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals]. / Handlungsorientierungen Bezugspflegender in der Beziehungsgestaltung mit ihren Patient_innen im Maßregelvollzug.

Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals Abstract: Background: Building interpersonal relationships with patients is one of the most elementary tasks of mental health nurses in forensic psychiatric hospitals and should be considered as the core of their professional identity. The attitude of forensic psychiatric nurses has a substantial impact on building relationships even though this is often not immediately obvious as an implicit concept. Research question: Which types of action orientation of primary nurses characterize the building of relationships with their patients in forensic psychiatric hospitals? Methodology: To record the collective orientations of nurses, two group discussions were held with eight participants. The evaluation was carried out based on the documentary method. Results: Four types of orientations could be grouped into a generalizable basic typology. The focus is set on the relationship as a necessary precondition for successful cooperation with the patient. Honesty and mutual trust are significant features. Conversations about everyday topics facilitate relationship building. Openness and a genuine interest in the patient are equally as important as the definition and maintenance of personal boundaries. Conclusion: Implicit, action-oriented attitudes of forensic psychiatric nurses should be reflectively accessed in order to define professional relationships and maintain their boundaries. To achieve this, nurses need to have a structured framework to facilitate self-reflection and self-awareness. The goal is the systematic development of personal and interactional competences.

Influence of the birthing room design on midwives' job satisfaction - A cross-sectional online survey embedded in the 'Be-Up' study.

BACKGROUND: Job satisfaction is an important factor influencing work performance, personal well-being, commitment and retention. The working environment influences job satisfaction. The design of the birthing room could influence the practice of midwives and their satisfaction. This study investigates whether the alternative design of the birthing room implemented in the randomized controlled trial 'Be-Up' (Birth environment-Upright position) has an impact on job satisfaction of midwives. METHOD: A cross-sectional survey using an online questionnaire with 50 items addressing job satisfaction and birth room design was performed. The sample (n = 312) consists of midwives whose obstetric units participated in the Be-Up study and, as comparison group, midwives working in non-study obstetric units. These two independent groups were compared using t-tests; correlations and impacts were examined. RESULTS: The results of the T-tests revealed statistically significant higher global job satisfaction and higher satisfaction with team support of midwives in the Be-Up room. However, midwives working in customary birthing rooms were more satisfied with the design of the room. The most important predictors of job satisfaction were team factors and understaffing in both groups. CONCLUSION: Reasons for diminished satisfaction with the working environment in the Be-Up study may be assumed in uncertainties about emergency management in a new and unfamiliar environment. Furthermore the impact of a single redesigned room within a customary obstetric unit on job satisfaction seems small, as the room is embedded in the ward and hospital environment. More comprehensive concepts on the potential of the work environment influencing midwives' job satisfaction are needed.

Effect of alternatively designed hospital birthing rooms on the rate of vaginal births: Multicentre randomised controlled trial Be-Up.

BACKGROUND: There is limited research into the effects of the birth environment on birth outcomes. AIM: To investigate the effect of a hospital birthing room designed to encourage mobility, self-determination and uptake of upright maternal positions in labour on the rate of vaginal births. METHODS: The multicentre randomised controlled trial Be-Up, conducted from April 2018 to May 2021 in 22 hospitals in Germany, included 3719 pregnant women with a singleton pregnancy in cephalic position at term. In the intervention birthing room, the bed was removed or covered in a corner of the room and materials were provided to promote upright maternal positions, physical mobility and self-determination. No changes were made in the control birthing room. The primary outcome was probability of vaginal births; secondary outcomes were episiotomy, perineal tears degree 3 and 4, epidural anaesthesia, "critical outcome of newborns at term", and maternal self-determination (LAS). ANALYSIS: intention-to-treat. FINDINGS: The rate of vaginal births was 89.1 % (95 % CI 87.5-90.4%; n = 1836) in the intervention group and 88.5 % (95 % CI 87.0-89.9 %; n = 1863) in the control group. The risk difference in the probability of vaginal birth was + 0.54 % (95 % CI - 1.49 % to 2.57 %), the odds ratio was 1.06 (95 % CI 0.86-1.30). Neither the secondary endpoints nor serious adverse events showed significant differences. Regardless of group assignment, there was a significant association between upright maternal body position and maternal self-determination. CONCLUSION: The increased vaginal birth rates in both comparison groups can be explained by the high motivation of the women and the staff.

[Advanced Nursing Practice (ANP) in the practice of mental health nursing in Germany: A phenomenological study]. / Advanced Nursing Practice (ANP) in der psychiatrischen Pflege in Deutschland.

Advanced Nursing Practice (ANP) in the practice of mental health nursing in Germany: A phenomenological study Abstract. Background: The wide variety and constantly changing selection of offered psychiatric care services, in combination with the demand for high quality nursing practice supports the integration of Advanced Practice Nurses (APN). The literature presents a multifaceted picture of APNs working in psychiatric services. Individually chosen emphasis was especially prevalent in the field of care. Gaps in research persist concerning the clinical scope of responsibility. Aim: How does the ANP phenomenon find expression in German clinical psychiatric practice? Method: The dataset comprises problem-focused interviews with three expert APNs from different hospitals. The interviews took place between April and October 2019. Applied phenomenology was used to analyze and interpret the dataset. Results: Soft skills and clinical leadership are pivotal competencies for APNs to perform efficiently in clinical practice. Profound life and work experience are key factors in terms of impact. Conclusions: To perform efficiently, APNs require professional and methodological knowledge at a master's level, profound soft skills as well as clinical leadership expertise. Higher education and further curricular training are required. Establishing APNs in clinical psychiatric practice depends primarily on the decisions of managers in nursing. The management of nursing needs to adopt new care structures that allow APNs to implement their qualifications in the psychiatric care system.

The partner's experiences of childbirth in countries with a highly developed clinical setting: a scoping review.

BACKGROUND: In Western countries, it is common practice for a woman to be supported by a trusted person during childbirth, usually the other parent. Numerous studies have shown that this has a positive effect both on the woman's satisfaction with the birth process and on physical outcomes. However, there is little research on the birth experience of partners and their wellbeing. The aim of this review is to summarise the existing literature on partner experience, consider its quality and identify the underlying themes. METHODS: Both a systematic literature search in three databases and a manual search were conducted, for qualitative, quantitative, and mixed-methods studies from Western countries examining the experiences of partners present at a birth. RESULTS: A total of 35 studies were included. Only one study included same-sex partners (the other studies addressed fathers' experiences only) and only one validated questionnaire examining partners' birth experiences was identified. Four major themes were found to influence partners' birth experiences: (1) intense feelings, (2) role of support, (3) staff support, and (4) becoming a father. CONCLUSIONS: Partners may feel very vulnerable and stressed in this unfamiliar situation. They need emotional and informal support from staff, want to be actively involved, and play an important role for the birthing woman. To promote good attachment for parents, systematic exploration of the needs of partners is essential for a positive birth experience. Because of the diversity of family constellations, all partners should be included in further studies, especially same-sex partners.

Measuring job satisfaction of midwives: A scoping review.

BACKGROUND: Given the global shortage of midwives, it is of utmost interest to improve midwives' job satisfaction and working environments. Precise measurement tools are needed to identify both predictors of job satisfaction and intervention strategies which could increase it. The aim of this study is to collate, describe and analyse instruments used in research to assess the job satisfaction of midwives working in hospitals, to identify valid and reliable tools and to make recommendations for the further development of specific instruments for midwifery practice and future midwifery research. METHODS: We conducted systematic literature searches of the following databases: CINAHL, MEDLINE, PsycINFO, Web of Science Core Collection, Cochrane Database. Studies which assessed the job satisfaction of midwives working in a hospital setting were eligible for inclusion. FINDINGS: Out of 637 records 36 empirical research articles were analysed, 27 of them cross-sectional studies. The studies had been conducted in 23 different countries, with sample sizes ranging between nine and 5.446 participants. Over 30 different instruments were used to measure midwives' job satisfaction, with considerable differences in terms of domains evaluated and number of items. Twelve domains relevant for job satisfaction of midwives working in hospitals were identified from the empirical studies. Four instruments met the defined reliability and validity criteria. CONCLUSION: Autonomy, the significance of the job, the challenges of balancing work and private life, and the high emotional and physical demands of midwifery are job characteristics which are underrepresented in instruments measuring job satisfaction. The influence of the physical working environment has also not yet been researched. There is a need to develop or adapt instruments to the working environment of midwives.

Midwives' action-guiding orientation while attending hospital births - A scoping review.

Following the "call for action to research", various aspects of maternity care should be examined so that perinatal care can be improved based on evidence. Clinical midwifery is the most common way of attending births in high-income countries. Midwives are the experts for normal labor and birth and play a central role in caring for women giving birth in a hospital setting. The aim of this scoping review was to explore midwives' action-guiding orientation in their care provision during hospital births in high-income countries. Four databases (CINAHL, PubMed, MEDLINE and PSYNDEX) were searched systematically for studies in English or German on midwives' action-guiding orientation during hospital labor and birth, published between 2000 and February 2022. Only studies from peer-reviewed journals were included. Reporting followed the PRISMA-ScR statement for scoping reviews. From a total of 1572 studies, 26 studies with 4 different research designs were included in the narrative synthesis. The synthesis shows 7 central concepts that emerge in the studies: medicalization of birth versus woman-centered care; midwives' knowledge and experience; midwives' professional identity; midwives' confidence or autonomy in practice; intra-professional and multi-professional relations; continuity of care and relationship with the woman; and working conditions and cultural context. The central concept most reflective of midwives' action-guiding orientation was "medicalization of birth versus woman-centered care." Other elements that affect midwives' action-guiding orientation and represent influencing factors at the micro, meso, and macro levels of obstetric care must be considered if one is to understand the profession and work of midwives.

[Quality-Assured Translation of the Wijma Delivery Expectancy Questionnaire (W-DEQ_A) into German]. / Qualitätsgesicherte Übersetzung des Wijma Delivery Expectancy Questionnaire (W-DEQ_A) ins Deutsche.

INTRODUCTION: The "Delivery Expectancy Questionnaire" by Claas Wijma et al. (W-DEQ_A), which is the most frequently used internationally to determine high levels of fear of childbirth in pregnancy, was not previously available in German. In European countries, Canada, Australia and the United States, fear of childbirth is reported to have a prevalence of 6.3 to 14.8%. Particularly, women with a fear of childbirth have an increased risk for preeclampsia, intrauterine growth retardation, and caesarean sections. METHODS: An English version of the W-DEQ_A authorized by Claas Wijma was translated and culturally adapted according to the guideline of Ohrbach et al. (INfORM). Content validity was statistically determined by means of the content validity index/average method (S-CVI/Ave). RESULTS: The translation of all text sections of the W-DEQ_A was subjected to independent appraisal. One introductory question and three items needed to be retranslated. Moreover, three items required rewording to achieve cultural equivalence. The calculated content validity yielded an "excellent" S-CVI/Ave of 0.91. CONCLUSION: The W-DEQ_A is now available in a German version for the self-assessment of fear of childbirth. It is entitled "Gedanken und Gefühle schwangerer Frauen im Hinblick auf die bevorstehende Geburt". In the form of a digital health app, the questionnaire could be prescribed and the result directly transferred to the electronic patient record.

Effects of the Covid-19 pandemic on maternity staff in 2020 - a scoping review.

In the spring of 2020, the SARS-CoV-2 virus caused the Covid-19 pandemic, bringing with it drastic changes and challenges for health systems and medical staff. Among the affected were obstetricians and midwives, whose close physical contact with pregnant women, women who recently gave birth, and their children was indispensable. In the obstetric setting, births cannot be postponed, and maternity staff had to adapt to assure obstetric safety while balancing evidence-based standards with the new challenges posed by the pandemic. This scoping review gives a comprehensive overview of the effecs the Covid-19 pandemic had on maternity staff. We followed the evidence-based approach described by Arksey & O'Malley: we searched several databases for English and German articles published between January 2020 and January 2021 that discussed or touched upon the effects the pandemic had on maternity staff in OECD countries and China. We found that structural challenges caused by the crisis and its subjective effects on maternity staff fell into two main topic areas. Structural challenges (the first main topic) were divided into five subtopics: staff shortages and restructuring; personal protective equipment and tests; switching to virtual communication; handling women with a positive SARS-CoV-2 infection; and excluding accompanying persons. The pandemic also strongly affected the staff's mental health (the second main topic.) Attempting to meet challenges posed by the pandemic while afraid of contamination, suffering overwork and exhaustion, and struggling to resolve ethical-moral dilemmas had severe negative subjective effects. Several studies indicated increased depression, anxiety, stress levels, and risk of post-traumatic stress symptoms, although the crisis also generated strong occupational solidarity. Care for pregnant, birthing, and breast-feeding women cannot be interrupted, even during a pandemic crisis that requires social distancing. Maternity staff sometimes had to abandon normal standards of obstetric care and were confronted with enormous challenges and structural adjustments that did not leave them unscathed: their mental health suffered considerably. Researchers should study maternity staff's experiences during the pandemic to prepare recommendations that will protect staff during future epidemics.

Methodological challenges and solution strategies during implementation of a midwife-led multicenter randomized controlled trial (RCT) in maternity hospitals.

BACKGROUND: Randomized controlled trials (RCTs), especially multicentric, with complex interventions are methodically challenging. Careful planning under everyday conditions in compliance with the relevant international quality standard (Good Clinical Practice [GCP] guideline) is crucial. Specific challenges exist for RCTs conducted in delivery rooms due to various factors that cannot be planned beforehand. Few published RCTs report challenges and problems in implementing complex interventions in maternity wards. In Germany as well as in other countries, midwives and obstetricians have frequently little experience as investigators in clinical trials. METHODS: The aim is to describe the key methodological and organizational challenges in conducting a multicenter study in maternity wards and the solution strategies applied to them. In particular, project-related and process-oriented challenges for hospital staff are considered. The exemplarily presented randomized controlled trial "BE-UP" investigates the effectiveness of an alternative design of a birthing room on the rate of vaginal births and women-specific outcomes. RESULTS: The results are presented in five sectors: 1) Selection of and support for cooperating hospitals: they are to be selected according to predefined criteria, and strategies to offer continuous support in trial implementation must be mapped out. 2) Establishing a process of requesting informed consent: a quality-assured process to inform pregnant women early on must be feasible and effective. 3) Individual digital real-time randomization: In addition to instructing maternity teams, appropriate measures for technical failure must be provided. 4) The standardized birthing room: The complex intervention is to be implemented according to the study protocol yet adapted to the prevailing conditions in the delivery rooms. 5) GCP-compliant documentation: midwives and obstetricians will be instructed in high-quality data collection, supported by external monitoring throughout the trial. CONCLUSION: Since not all potential challenges can be anticipated in the planning of a trial, study teams need to be flexible and react promptly to any problems that threaten recruitment or the implementation of the complex intervention. Thought should be given to the perspectives of midwives and obstetricians as recruiters and how clinic-intern processes could be adapted to correspond with the trial's requirements. TRIAL REGISTRATION: The BE-UP study was registered on 07/03/ 2018 in the German Register for Clinical Trials under Reference No. DRKS00012854 and can also be found on the International Clinical Trials Registry Platform (ICTRP) (see https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS0001285 ).

Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy - a Prospective, Randomised, Controlled Interventional Study.

Background Women have a markedly increased lifetime risk for cardiovascular morbidity and mortality following hypertensive disorders of pregnancy. Arterial stiffness is regarded as a target parameter for reducing cardiovascular risk and can be modified by lifestyle changes. Methods In a prospective, randomised, controlled interventional study, starting 6 weeks postpartum, the effect of nutritional intervention combined with an intensive 6-month cardiovascular exercise programme on arterial stiffness was investigated by means of pulse wave velocity (PWV) in 38 women with severe hypertensive disorder of pregnancy (preeclampsia with or without pre-existing hypertension and/or HELLP syndrome). A reference group was formed with postpartum women without pregnancy complications or known cardiovascular risk and the arterial stiffness was studied by means of PWV at the time of delivery. The PWV was measured in the intervention and control groups within a week after delivery and after 32 weeks (6 weeks + 6 months). A feasibility analysis was performed in addition. Results 29 of 38 women with severe hypertensive disorder of pregnancy and 38 postpartum women in the reference group were included in the analysis (intervention group n = 14; control group n = 15; reference group n = 38). Adherence to a) the nutritional counselling and b) the intensive cardiovascular exercise programme was 73% and 79% respectively. A clinically significant difference (d = 0.65) in pulse wave velocity between the intervention and control groups was found after 6 months (6.36 ± 0.76 vs. 7.33 ± 2.25 m/s; group × time: p = 0.632). The PWV of the intervention group corresponded to that of the reference group at the end of the study (6.36 ± 0.76 m/s vs. 6.5 ± 0.70; d = 0.19), while the results in the control group differed markedly from this (7.33 ± 2.25 m/s; d = 0.56). Conclusion The study documents the feasibility of lifestyle intervention with physical exercise after delivery (starting 6 weeks postpartum). The intervention showed a significant clinical effect by reducing arterial stiffness to the level of the reference group. Before this intervention can be included in the standard of care and prevention, follow-up studies must confirm these results and the medium-term effects on cardiovascular risk.

Fear of childbirth (FOC): pregnant women's perceptions towards the impending hospital birth and coping resources - a reconstructive study.

Background: To provide obstetric care which meets the needs of pregnant women with fear of childbirth (FOC), a deeper understanding is required of the beliefs of these women regarding their impending birth and the coping resources they possess to cope with their fear.Methods: Problem-centred interviews were carried out with 12 pregnant women who self-reported high FOC. Data analysis was performed using Bohnsack's Documentary Method to reconstruct collective frames of orientation and implicit and explicit orientations in daily practice and interaction.Results: The interviewees see birth as a field of tension between the poles of naturalness and medicalization. Their need for information displays a need to be in control and fear of losing control. Medical and technological monitoring and one-to-one care promote security. Pregnant women with FOC want to know how they can contribute to a physiological birth.Conclusions: Structural, organizational and conceptual changes in obstetric care are needed to cater to the needs of pregnant women with FOC. Alongside the need for evidence-based information about non-medical and medical pain-relief as well as decision-making aids, the provision of a continuity model of midwifery care is important.

Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial.

BACKGROUND: Caesarean sections (CSs) are associated with increased risk for maternal morbidity and mortality. The recommendations of the recently published German national health goal 'Health in Childbirth' (Gesundheit rund um die Geburt) promote vaginal births (VBs). This randomised controlled trial (RCT) evaluates the effects of a complex intervention pertaining to the birth environment, based on the sociology of technical artefacts and symbolic interactionism. The intervention is intended to foster an upright position and mobility during labour, which lead to a higher probability of VB. METHODS/DESIGN: This study is an active controlled superiority trial with a two-arm parallel design. The complex intervention involves making changes to the birthing room to encourage an upright position and mobility of women in labour and to relax them, which may help them to cope with labour and may increase self-determination. This may result in more VBs. Included in the study are primiparae and multiparae with a singleton foetus in cephalic presentation at term planning a VB. According to the sample size calculation, 3800 women in 12 obstetrical units are to be included. Randomisation will be performed centrally and controlled by an independent coordination centre. Blinding of participants and staff is not possible. Key outcomes are VB, episiotomy, perineal tears, epidural analgesia, critical outcome of newborn at term and maternal self-determination during birth. Additionally, a health economic evaluation will be performed. DISCUSSION: This is the first adequately powered multicentre RCT examining the effect of a redesigned birthing room on the probability of a VB and patient-centred physical and emotional outcomes. An increase in the number of VBs by 5% from a baseline of 74% to 79% would result in 21,000 women per year experiencing a VB rather than a CS in Germany. Expected benefits are greater self-determination during labour, improved physical and emotional client-centred outcomes, fewer medical interventions and a reduction in health-care costs. TRIAL REGISTRATION: German Clinical Trials Register (Deutsches Register Klinischer Studien), DRKS00012854 . Registered on 7 March 2018.

Midwives' perceptions of women's preferences related to midwifery care in Germany: A focus group study.

OBJECTIVE: To explore how midwives perceive patient preferences related to midwifery care in Germany. DESIGN: This qualitative study, which was part of a larger study, used a hermeneutic-interpretive approach and involved focus group interviews with midwives. Data collection and analysis were done in a conjoined fashion between April 2015 and September 2016. SETTING: Four focus group interviews were conducted in four different federal states of Germany. PARTICIPANTS: The sample of 20 qualified midwives was heterogeneous with regards to age, educational level, professional experience, type of midwifery care provided, and setting (employed, caseload, education) in which they provided services. FINDINGS: Three main themes were identified: Strengths and limitations of midwives' present professional profile (midwives' area of responsibility, range of services, and competency); lack of midwives and midwifery services; women's experiences of conflict in interprofessional care. Each main theme is broken down into several aspects of content. Many women are not aware of the scope of professional knowledge and expertise of midwives. Moreover, the poor delineation of midwives' and obstetricians' areas of competency in Germany's hospitals seems to be disadvantageous for the women. Midwives feel that due to context implications they cannot live up to the quality of midwifery care they aspire to. Lack of midwives results in midwives being overwhelmed, women underserved, and both disappointed. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: On the one hand, new models of midwifery/maternity care need to be developed to solve some of the existing problems; on the other hand, new forms of interprofessional cooperation and management of transition of care points are required. Overall it is important that changes are implemented in such a way that women are enabled, and welcome, to clearly state their preferences for midwifery and maternity care. Particularly in Germany, tertiary education of midwives is needed to broaden their expertise and place them on an equal footing with obstetricians.

Support for pregnant women identified with fear of childbirth (FOC)/tokophobia - A systematic review of approaches and interventions.

BACKGROUND: providing appropriate care for pregnant women with high or severe fear of childbirth (FOC) is a challenge in midwifery care today. FOC is associated with predisposing anamnestic factors, various sociodemographic and psychosocial characteristics, and may result in serious healthrelated consequences. It is therefore important to establish which interventions may increase a woman's faith in her own ability to cope with labour and birth. AIM: to systematically identify and review studies examining interventions for relief of severe fear of childbirth in pregnancy and their underlying conceptual foundation. METHODS: a systematic literature search was performed following Cochrane Collaboration and PRISMA Statement recommendations. Inclusion criteria were: studies including pregnant women diagnosed with high or severe FOC or who requested a caesarean section due to severe FOC, studies (regardless of design) observing the effect of an intervention addressing FOC, and studies published in English. Publications addressing anxiety or stress were excluded. 377 references were screened by title and abstract. The risk of bias was assessed. FINDINGS: 19 articles referring to 15 research projects were included in the analysis. The studies show heterogeneity regarding assessment methods, type, conceptualisation and application of interventions. There is evidence that both cognitive therapy sessions and a theory-based group psychoeducation with relaxation are effective interventions. KEY CONCLUSIONS: despite methodological limitations, single or group psychoeducation sessions for nulliparous women or therapeutic conversation during pregnancy (in group or individual sessions) have the potential to strengthen women's self-efficacy and decrease the number of caesarean sections due to FOC. The theoretical validation of an intervention deepens the understanding of psychological processes in women coping with severe FOC. IMPLICATIONS FOR PRACTICE: theory-based concepts of care for both antenatal and intrapartum support of pregnant women with high or severe FOC should be developed, piloted, tested, evaluated and implemented within the given healthcare system. Midwives need to be competent to address pregnant women's fears regarding labour and birth in antenatal care. The use of a valid assessment tool to identify the level of FOC in women, even if they do not raise the issue, is recommended in routine antenatal care so that appropriate expert support can be offered. A one-on-one conversation may be feasible for those women unwilling to fill in a questionnaire. Cooperative local networks between midwives, psychologists and obstetricians qualified in psychotherapy should be established to ensure timely and effective care for women with high or severe FOC.

Experiences and wishes of women regarding systemic aspects of midwifery care in Germany: a qualitative study with focus groups.

BACKGROUND: Knowledge of pregnant women's and mothers' viewpoints on midwifery care is crucial for its appropriate delivery and research. In Germany, comprehensive research to more fully understand women's needs in pregnancy, labour, birth and the postpartum period until weaning is lacking. International studies provide some knowledge of women's expectations, their choices, and subjective criteria indicating good midwifery care. METHODS: This study explores pregnant women's and mothers' experiences, needs and wishes regarding systemic aspects of midwifery care (access, availability, choices, model of midwifery care; maternity care in the healthcare system). 50 women participated in 10 focus groups in 5 states of Germany. The groups were heterogeneous with regard to age, parity, model of maternity care used, and rating of satisfaction. Women with limited educational years (n = 9) were personally contacted by midwives and reached by social media. Also, mothers living in a mother-child home (n = 6) or attending a peer group for grieving parents (n = 5) were included. The digitally documented focus groups were systematically analysed in an itinerary hermeneutic manner. RESULTS: Three themes were identified: (a) Knowledge or lack of awareness of midwifery care, (b) availability of and access to midwives, and (c) midwifery care in the healthcare system. Theme (a) entails the scope of midwifery care and the midwife's competence, but also a lack of information, inconsistent counselling, and difficulty identifying midwives. Theme (b) encompasses aspects such as the availability, accessibility and selection of a midwife, the effort involved in looking for a midwife, the challenge of transition points, and family midwives. Theme (c) relates interprofessional cooperation, gaps/inadequacies of care during latency phase, alternative models of care, and the importance of family and peer groups for women. CONCLUSIONS: Midwifery care and research in Germany must address the issue of imparting relevant information about midwifery services. Interprofessional cooperation and management of transition points ought to be improved in the interests of the women concerned. Moreover, the quality of antenatal classes, support during latency phase, and intrapartum care in hospitals need to be addressed. Lastly, the special needs of vulnerable women in midwifery care must become a major focus in Germany.

[Analysis of potential for research on giving birth in an upright position in German hospitals]. / Potenzialanalyse zur aufrechten Gebärhaltung bei physiologischen Geburten in deutschen Kreißsälen.

HEALTH PROBLEM: In German hospitals, three quarters of all low-risk pregnant women give birth in the supine position, despite the fact that German, British and WHO guidelines do not recommend a supine birthing position which is associated with a higher risk to the health of both mother and fetus. CORPUS OF EVIDENCE: Based on 22 RCTs with 7,280 participants, a systematic Cochrane review (Gupta et al., 2012) revealed that an upright position - compared with a supine or lithotomy position - (1) has a positive impact on fetal heart rate patterns, (2) reduces the requirement for analgesic or anaesthetic medications in the second stage of labour, and (3) results in fewer episiotomies and (4) fewer instrumental deliveries. There is a lack of evidence regarding perceived maternal autonomy, self-efficacy and anxiety when giving birth. Furthermore, evidence on long-term effects is absent. Some studies indicate that the choice of an upright birthing position might be boosted by a supporting physical and social environment and by specially trained midwives. IMPLICATION FOR RESEARCH: There is a need for a feasibility study and a subsequent cluster RCT in the German healthcare context in order to investigate the effects of the upright posture for birthing on perceived maternal autonomy, self-efficacy and anxiety, on the reduction of perinatal complications and on long-term complaints. The complex experimental intervention consists of (1) evidence-based and user-friendly information for women and their partners, (2) facilitating the choice for an upright labour position by special training for midwives and (3) providing a supportive physical and social environment. Within the first study phase, the exploration of feasibility in terms of access to the target group and acceptance of the intervention by pregnant women, their partners and midwives is recommended. Thereby, the implementation of guidelines for upright labour and birth, the documentation and collection of outcome and cost data could be evaluated. Non-German instruments for measuring benefits, harms and long-term effects could be adapted to and validated for the German context.

Key role in the prevention of child neglect and abuse in Germany: continuous care by qualified family midwives.

OBJECTIVE: the aim of two related studies was an in-depth knowledge of psychosocially and health-related vulnerable families and the 'portfolio' of care that family midwives (FM) provide. Besides factors which influence acceptance and access from the mothers' perspective, the effectiveness of FM with regard to care, infant nutrition, and parent-child relationship as well as multidisciplinary collaboration were of interest, especially against the backdrop of Germany's national aim to strengthen prevention of neglect and abuse of infants. In addition, the reasons why families did not want FM care were explored. DESIGN: two FM model projects in Saxony-Anhalt (SA) and Lower Saxony (LS), Germany, were evaluated. Quantitative data were prospectively collected on 93% of vulnerable families being cared for by FM (SA) and regarding vulnerable families that declined FM care (LS). These data were complemented by problem-focused interviews with 14 mothers and six social workers (LS). SETTING AND INTERVENTIONS: the 33 FM in SA and 11 FM in LS are community-based and visit vulnerable families from pregnancy up to the first birthday of the child, maximally. They provide health promotion, maternal and infant care, and multidisciplinary support geared towards early prevention of child neglect and abuse. PARTICIPANTS: from May 2006 until 2008 (SA) and from January 2008 until December 2009 (LS) 814 and 235 vulnerable families, respectively, were cared for by FM. Complete data on 734 families were analysed (SA) as were 30 questionnaires on 'non-compliant' families (LS). Problem-focused interviews were conducted with 14 mothers and 6 social workers (LS). MEASUREMENTS AND FINDINGS: many families exhibited a high vulnerability score of complex risk factors. Four vulnerability patterns were statistically extracted explaining 40% of the total variance. The highest frequencies of care activities related to infant care and nutrition, giving advice on the Mother-Child relationship, and psychosocial support. The Youth Welfare Services (YWS) were significant collaboration partners, especially regarding families whose child was taken out for safety reasons. By conclusion of care, significantly higher mean scores were observed regarding 'parent-child relationship' and 'maternal care for child' (compared to the outset of care) when mean duration of care was at least 6 months. The children who were taken out of their families had significantly lower scores in nutritional care, and were given solids at a significantly earlier time. From the mothers' perspective it was important to have early access to the FM and easy between-visits communication via phone calls, or text messages. They appreciated the physical and psychosocial care for the infant and herself, an uncomplicated transition from caseload midwifery, and collaboration among providers. Families who declined FM care wanted to stay with their self-chosen midwife, were afraid of external control, or felt they were able to cope without professional support. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: when families can access FM early on and home-visits are sustained, maternal competencies in caring for, and relating to, the child can potentially be strengthened. FM seem to fill a gap between standard care by caseload midwives ending at 8 weeks postpartum and YWS whose personnel is not skilled in the assessment of health-related problems, such as inadequate infant nutrition. As a relatively high percentage of the families were challenged by domestic violence, drug addiction, and teenage pregnancy, ongoing educational activities should address these topics.

The timing of interventions during labour: descriptive results of a longitudinal study.

OBJECTIVE: To describe the timing and frequency of interventions during labour, and in addition to compare the timings of the interventions against the partogram action lines. DESIGN: Longitudinal prospective and retrospective cohort study. SETTING: 47 Hospitals in Lower Saxony, Germany. PARTICIPANTS: 3963 Births of nulliparae and multiparae with singletons in vertex presentation giving birth between April and October 2005. The participation rate for the prospectively recruited sample (n = 1169) was 4.7%. MEASUREMENTS: Time intervals until intrapartal interventions were calculated by Kaplan-Meiers estimation. Outcome variables were duration of labour and mode of birth. FINDINGS: Multiparae had slightly longer median time intervals between the onset of labour and the beginning of care by the midwife than nulliparae. With regard to the intervals between the onset of labour and the occurrence of interventions, multiparae had shorter median durations than nulliparae in respect of amniotomy, oxytocin augmentation and neuraxial analgesia. By three hours after onset of labour 8.4% of nulliparae had received oxytocin augmentation, 10.7% neuraxial analgesia and 8.9% an amniotomy. Of multiparae, 9.1% had received oxytocin augmentation but only 5.6% neuraxial analgesia; 20.0% had had an amniotomy. The median time interval before the initiation of water immersion and massage was between three and four hours; that before the initiation of vertical positioning was 1.8 hours. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Current German practice without the use of partogram action lines reveals that early interventions were performed before the partogram action lines were met. Interventions applying midwifery care techniques such as vertical positioning preceded more invasive medical interventions during the process of childbirth.