Midwifery continuity of care for women with perinatal mental health conditions: A cohort study from Australia.

BACKGROUND: Perinatal mental health (PMH) conditions are associated with adverse outcomes such as maternal suicide, preterm birth and longer-term childhood sequelae. Midwifery continuity of care (one midwife or a small group of midwives) has demonstrated benefits for women and newborns, including a reduction in preterm birth and improvements in maternal anxiety/worry and depression. AIM: To determine if midwifery care provided through a Midwifery Group Caseload Practice model is associated with improved perinatal outcomes for women who have anxiety and depression and/or other perinatal mental health conditions. An EPDS ≥ 13, and/or answered the thought of harming myself has occurred to me and/or women who self-reported a history compared to standard models of care (mixed midwife/obstetric fragmented care). METHODS: A retrospective cohort study using data routinely collected via an electronic database between 1 January 2018 31st of January 2021. The population were women with current/history of PMH, who received Midwifery Caseload Group Practice (MCP), or standard care (SC). Data were analysed using descriptive statistics for maternal characteristics and logistic regression for birth outcomes. One-to-one matching of the MCP group with the SC group was based on propensity scores. RESULTS: 7,359 births were included MCP 12% and SC 88%. Anxiety was the most common PMH with the same proportion affected in MCP and SC. Adjusted odds of preterm birth and adverse perinatal outcomes were lower in the MCP group than the SC group (aOR (95%CI): 0.77 (0.55, 1.08) and 0.81 (0.68, 0.97), respectively) and higher for vaginal birth and full breastfeeding (aOR (95% CI): 1.87 (1.60, 2.18) and 2.06 (1.61, 2.63), respectively). In the matched sample the estimate of a relationship between MCP and preterm birth (aOR (95% CI): 0.88 (0.56, 1.42), adverse perinatal outcomes (aOR (95% CI): 0.83 (0.67, 1.05)) and breastfeeding at discharge (aOR (95% CI): 1.82 (1.30, 2.51)), stronger for vaginal birth (aOR (95% CI): 2.22 (1.77, 2.71)). CONCLUSION: This study supports positive associations between MCP and breastfeeding and vaginal birth. MCP was also associated with lower risk of adverse perinatal outcomes, though in the matched sample with a smaller sample size, the confidence interval included 1. The direction of the association MCP and preterm birth was negative (protective). However, in the matched sample analysis, the confidence interval was wide, and the finding was also consistent with no benefit from MCP. Randomised controlled trials are required to answer questions around preterm birth and adverse perinatal outcomes and further research is being planned.

Implementation and evaluation of a nurse-led intervention to augment an existing residential aged care facility outreach service with a visual telehealth consultation: stepped-wedge cluster randomised controlled trial.

BACKGROUND: Up to 75% of residents from residential aged care facilities (RACF) are transferred to emergency departments (ED) annually to access assessment and care for unplanned or acute health events. Emergency department presentations of RACF residents can be both expensive and risky, and many are unnecessary and preventable. Processes or triage systems to assess residents with a health event, prior to transfer, may reduce unnecessary ED transfer. The Aged Care Emergency (ACE) service is a nurse-led ED outreach service that provides telephone support to RACF nurses regarding residents' health events. This service is available Monday to Friday, 8am to 4 pm (ED ACE hours). The primary objective of this study was to assess whether the augmentation of the phone-based ED ACE service with the addition of a visual telehealth consultation (VTC) would reduce RACF rate of ED presentations compared to usual care. The secondary objectives were to 1) monitor presentations to ED within 48 h post VTC to detect any adverse events and 2) measure RACF staff perceptions of VTC useability and acceptability. METHODS: This implementation study used a stepped wedge cluster randomised controlled trial design. Study settings were four public hospital EDs and 16 RACFs in two Local Health Districts. Each ED was linked to 4 RACFs with approximately 350 RACF beds, totalling 1435 beds across 16 participating RACFs. Facilities were randomised into eight clusters with each cluster comprising one ED and two RACFs. RESULTS: A negative binomial regression demonstrated a 29% post-implementation reduction in the rate of ED presentations (per 100 RACF beds), within ED ACE hours (IRR [95% CI]: 0.71 [0.46, 1. 09]; p = 0.122). A 29% reduction, whilst not statistically significant, is still clinically important and impactful for residents and EDs. A post-hoc logistic regression demonstrated a statistically significant 69% reduction in the probability that an episode of care resulted in an ED presentation within ED ACE hours post-implementation compared to pre-implementation (OR [95% CI]: 0.31 [0.11, 0.87]; p = 0.025). CONCLUSION: Findings have shown the positive impact of augmenting ACE with a VTC. Any reduction of resident presentations to a busy ED is beneficial to healthcare overall, but more so to the individual older person who can recover safely and comfortably in their own RACF. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ID ACTR N12619001692123) (02/12/2019) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378629andisReview=true.

Experiences of nurses working in RACFs and EDs utilising visual telehealth consultation to assess the need for RACF resident transfer to ED: A qualitative descriptive study.

AIMS AND OBJECTIVES: This study aimed to explore whether an intervention using visual telehealth improves care outcomes for residents in residential aged care facilities during acute illness events from the perspective of the nurses from residential aged care facilities and emergency departments. The intervention was the addition of visual telehealth, to an already existing outreach service called Aged Care Emergency. BACKGROUND: Older people who are residents of residential aged care facilities commonly experience potentially avoidable visits and hospitalisations. Adopting visual telehealth or telemedicine has emerged as a care transition solution across several domains in health care, including residential aged care. METHOD: This study used an interpretive descriptive methodological approach and was part of a larger study called the PACE-IT project that implemented a visual telehealth assisted model of care in four emergency departments and 16 residential aged care facilities to prevent unnecessary resident presentations to emergency departments. We report findings from six focus groups that explored key issues relating to the experiences of emergency department and residential aged care nurses who participated in the PACE-IT project. This study adhered to COREQ research guidelines. RESULTS: There were four overarching themes that emerged from the six focus groups; facilitated person centred care; built confidence, relationships and trust; enabled bidirectional communication that strengthens decision making, but there were issues with technology access, connectivity and usability between the acute care setting and the residential aged care facility. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of residential aged care facility and emergency nurses' experiences when using visual telehealth will better inform practice development in aged care, in particular enhancing decision making and increasing safe practices using telehealth. The knowledge gained in this study in terms of enhanced assessments for residents will provide policy makers with valuable insights for future health care planning and implementation of telehealth. TRIAL REGISTRATION: ACTRN12619001692123.

A cross-sectional survey of Australian healthcare professionals' confidence, evidence-based knowledge and guideline use for antenatal asthma management.

BACKGROUND: Asthma is one of the most common chronic health conditions experienced during pregnancy and is associated with numerous adverse maternal and perinatal outcomes. AIMS: To better understand the confidence, evidence-based knowledge and guideline use among healthcare professionals around Australia commonly involved in providing antenatal care for women with asthma. MATERIALS AND METHODS: An online, cross-sectional survey was developed and distributed to maternity carers (obstetricians and midwives), primary carers (general practitioners and general practice nurses) and respiratory specialists (respiratory physicians and respiratory nurses). Self-reported confidence and use of clinical guidelines were recorded. Evidence-based knowledge was assessed with 13 questions relating to four clinical scenarios that covered recommendations from national and international guidelines. RESULTS: Primary carers and respiratory specialists were more confident in providing antenatal asthma care, more likely to use clinical guidelines and scored significantly higher in evidence-based knowledge of antenatal asthma management than maternity carers (P < 0.01 and P < 0.001, respectively). There was no significant difference in evidence-based knowledge among healthcare professionals from metropolitan, regional and rural backgrounds. However, healthcare professionals who used clinical guidelines scored significantly higher than those who did not (P < 0.0001). CONCLUSION: Greater utilisation of clinical guidelines could improve the evidence-based knowledge of maternity carers. However, the absence of antenatal asthma management in obstetric- and maternity-specific guidelines poses a potential barrier that needs to be addressed. Furthermore, the development of multidisciplinary antenatal clinics, staffed by respiratory nurses and/or physicians, could improve outcomes for pregnant women with asthma who are not undertaking shared care.

Inter-hospital and inter-disciplinary variation in planned birth practices and readiness for change: a survey study.

BACKGROUND: How the application of evidence to planned birth practices, induction of labour (IOL) and prelabour caesarean (CS), differs between Australian maternity units remains poorly understood. Perceptions of readiness for practice change and resources to implement change in individual units are also unclear. AIM: To identify inter-hospital and inter-professional variations in relation to current planned birth practices and readiness for change, reported by clinicians in 7 maternity units. METHOD: Custom-created survey of maternity staff at 7 Sydney hospitals, with questions about women's engagement with decision making, indications for planned birth, timing of birth and readiness for change. Responses from midwives and medical staff, and from each hospital, were compared. FINDINGS: Of 245 completed surveys (27% response rate), 78% were midwives and 22% medical staff. Substantial inter-hospital variation was noted for stated planned birth indication, timing, women's involvement in decision-making practices, as well as in staff perceptions of their unit's readiness for change. Overall, 48% (range 31-64%) and 64% (range 39-89%) agreed on a need to change their unit's caesarean and induction practices respectively. The three units where greatest need for change was perceived also had least readiness for change in terms of leadership, culture, and resources. Regarding inter-disciplinary variation, medical staff were more likely than midwifery staff to believe women were appropriately informed and less likely to believe unit practice change was required. CONCLUSION: Planned birth practices and change readiness varied between participating hospitals and professional groups. Hospitals with greatest perceived need for change perceived least resources to implement such change.

The impact of Healthy Conversation Skills training on health professionals' barriers to having behaviour change conversations: a pre-post survey using the Theoretical Domains Framework.

BACKGROUND: Changing people's behaviour by giving advice and instruction, as traditionally provided in healthcare consultations, is usually ineffective. Healthy Conversation Skills (HCS) training enhances health professionals' communication skills and ability to empower and motivate people in health behaviour change. Guided by the Theoretical Domains Framework (TDF), this study examined the impact of HCS training on health professional barriers to conducting behaviour change conversations in both clinical and non-clinical settings. Secondary aims were to i) identify health professionals' barriers to having behaviour change conversations, and explore the ii) effect of HCS training on health professionals' competence and attitudes to adopting HCS, iii) feasibility, acceptability and appropriateness of using HCS in their clinical and non-clinical roles, and iv) acceptability and quality of HCS training. METHODS: HCS training was conducted in October-November 2019 and February 2020. Pre-training (T1), post-training (T2) and follow-up (T3; 6-10 weeks post-training) surveys collected data on demographics and changes in competence, confidence, importance and usefulness (10-point Likert scale, where 10 = highest score) of conducting behaviour change conversations. Validated items assessing barriers to having these conversations were based on eight TDF domains. Post-training acceptability and quality of training was assessed. Data were summarised using descriptive statistics, and differences between TDF domain scores at the specific time points were analysed using Wilcoxon matched-pairs signed-rank tests. RESULTS: Sixty-four participants consented to complete surveys (97% women; 16% identified as Aboriginal), with 37 employed in clinical settings and 27 in non-clinical settings. The training improved scores for the TDF domains of skills (T1: median (interquartile range) = 4.7(3.3-5.3); T3 = 5.7(5.3-6.0), p < 0.01), belief about capabilities (T1 = 4.7(3.3-6.0); T3 = 5.7(5.0-6.0), p < 0.01), and goals (T1 = 4.3(3.7-5.0); T3 = 4.7(4.3-5.3), p < 0.01) at follow-up. Competence in using 'open discovery questions' increased post-training (T1 = 25% of responses; T2 = 96% of responses; T3 = 87% of responses, p < 0.001), as did participants' confidence for having behaviour change conversations (T1 = 6.0(4.7-7.6); T2 = 8.1(7.1-8.8), p < 0.001), including an increased confidence in having behaviour change conversations with Aboriginal clients (T1 = 5.0(2.7-6.3); T2 = 7.6(6.4-8.3), p < 0.001). CONCLUSIONS: Provision of additional support strategies to address intentions; memory, attention and decision processes; and behavioural regulation may enhance adoption and maintenance of HCS in routine practice. Wider implementation of HCS training could be an effective strategy to building capacity and support health professionals to use a person-centred, opportunistic approach to health behaviour change.

Patterns and predictors of gestational weight gain in Addis Ababa, Central Ethiopia: a prospective cohort study.

INTRODUCTION: Gaining excessive or inadequate gestational weight is associated with many adverse maternal and fetal outcomes. Inadequate gestational weight gain (GWG) increases the risk of fetal growth restriction, pre-term birth, and low birth weight. It is a public health concern in sub-Saharan Africa. The aim of this study was to assess the patterns and predictors of GWG in Addis Ababa, Ethiopia. METHODS: We conducted a prospective cohort study among pregnant women who attended antenatal care in health centres in Addis Ababa, from January to September 2019. Data were collected by a structured questionnaire and checklists and analysed using Stata version-14. Weight at or before 16 weeks gestation was used as a proxy for pre-pregnancy weight. Women's height and baseline weight were measured by data collectors, and we obtained weight at the end of the 24th and 36th weeks of gestation from women's medical records. GWG was categorized as inadequate, adequate and excessive based on the United States Institute of Medicine criteria. Predictors of GWG were identified using multinomial logistic regression. RESULTS: A total of 395 pregnant women were enrolled in the study. GWG was assessed for 369 (93%) women. The median GWG was 8.7 kg with inter quartile ranges (25th, 75th percentiles) of 7.0 kg and 11.6 kg. More than two-third of the participants, 248 (67.2% [95% CI: 62.2, 72.0%]), gained inadequate weight; 103 (27.9% [95% CI: 23.4, 32.8%]) gained adequate weight; and 18 (4.9% [95% CI: 2.9%, 7.6%]) gained excessive weight. Three quarters (75%) of underweight women gained inadequate gestational weight, whereas 43% of overweight or obese women gained inadequate gestational weight. Being underweight (AOR = 3.30 [95% CI: 1.32, 8.24]) or normal weight (AOR = 2.68 [95% CI: 1.37, 5.24]) before pregnancy increased the odds of gaining inadequate gestational weight compared to overweight or obese women. Not having paid employment was associated with higher odds of gaining inadequate gestational weight compared to women employed outside the home (AOR = 2.17 [95% CI: 1.16, 4.07]). CONCLUSIONS: Most pregnant women in Addis Ababa gain inadequate gestational weight. In particular, three quarters of underweight women gained inadequate gestational weight. Being underweight, normal weight or having no paid employment were associated with higher odds of inadequate GWG. Promoting adequate GWG in Addis Ababa among underweight and normal weight women may be an important public health initiative.

Pregnant women are expected to gain weight due to various biological changes. Gaining inadequate or excessive weight during pregnancy poses a health risk to the mother and baby. Inadequate weight gain is a public health concern in low-income countries, including Ethiopia. This study assessed patterns and predictors of weight gain during pregnancy in Addis Ababa, Central Ethiopia. The study was conducted from January to September 2019. Women attending public health facilities were followed from before or at 16 weeks of gestation until 36 weeks of pregnancy. A total of 395 pregnant women enrolled in the study. Weight gain was assessed for 369 (93%) women. More than two-third of the participants (67.2%) gained inadequate weight during pregnancy. Three quarters (75%) of underweight women gained inadequate weight, whereas 43% of overweight or obese women gained inadequate weight during pregnancy. Promoting adequate weight gain during pregnancy for underweight and normal weight women in Addis Ababa is an important public health initiative.

What gets measured gets noticed. Tracking surgical site infection post caesarean section through community surveillance: A post intervention study protocol.

AIM: This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section. DESIGN: This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section. METHODS: This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020-2021, at an Australian tertiary referral hospital. The text message invites women to complete a web-based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually). INTERVENTION: the proposed "HealthTracker" surveillance system facilitates active patient-reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire. DISCUSSION: This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention. IMPACT: Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates. TRIAL REGISTRATION: ACTRN12620001233910.

Intrapartum antibiotic prophylaxis for women who are screened positive for group B streptococcal colonisation: Clinical compliance with the guideline.

BACKGROUND: In high income countries, ~30% of pregnant women are provided with intrapartum antibiotic prophylaxis (IAP) for early-onset group B streptococcal infection (EOGBSI). The infection rate is low, 0.2/1000 livebirths in our jurisdiction, and others. We hypothesised factors, other than IAP alone, were reasons for the low rate of EOGBSI. AIMS: Compliance with our local guideline, referred to here as 'the guideline'. METHOD: Compliance was defined as an initial dose of benzylpenicillin IAP followed by four-hourly doses until birth. The study population was drawn from 4098 women who had 4100 pregnancies resulting in 4200 babies in an Australian birth setting from 1/1/2016 to 31/12/2016. Most, 93%, were eligible for universal GBS screening, 67% were reported as screened and 90% of these had a result documented; 23% were positive for GBS. A random sample (n = 223) was taken for further analysis. RESULTS: The adjusted odds of receiving benzylpenicillin IAP in accord with the guideline were three times higher among primiparous compared to multiparous women (P < 0.001, odds ratio (OR) = 3.4, 95% CI 1.7-6.7) and three times higher among women experiencing induction of labour compared to women who commenced labour spontaneously (P < 0.001, OR = 3.4, 95% CI 1.8-6.3). Of the 223 women, 188 received IAP: 176 received benzylpenicillin IAP, 31% (or 24% of the total sample) received this intervention in accord with the guideline, 24% received benzylpenicillin ≥4 h before birth but not in accord with the guideline and 44% received benzylpenicillin <4 h before birth. CONCLUSION: We conclude that sub-optimal compliance was largely a consequence of an unrealistic guideline.

COVID-19 preparedness in aged care: A qualitative study exploring residential aged care facility managers experiences planning for a pandemic.

AIMS AND OBJECTIVES: The study aims to understand the changing context of RACFs and the role of RACF managers in preparing to confront the COVID-19 pandemic and to provide insights into how the use of visual telehealth consultation might be incorporated to assist with managing whatever might arise. DESIGN: An interpretive descriptive study design was employed, and data were collected using semi-structured interviews conducted via telephone or videoconference. Purposive recruitment targeted clinical managers responsible for the COVID-19 response in RACFs. METHODS: RACF clinical managers were invited to discuss their responses to COVID-19 including the management of RACF and staff. Semi-structured interviews explored the COVID-19-related challenges, the response to these challenges and how telehealth might assist in overcoming some of these challenges. This study followed Thorne's (2008) three-stage process of interpretive description. The COREQ checklist was used in preparing this manuscript. RESULTS: Two main themes were identified. The first theme 'keeping people safe' was comprised of three subthemes; fear and uncertainty, managing the risks and retaining and recruiting staff. The second theme was 'keeping people connected', had two subthemes; being disconnected and isolated and embracing technology. CONCLUSION: Findings from this study provide valuable insight into understanding the context and the challenges for RACFs and the staff as they attempt to keep residents safe and connected with healthcare providers and the outside world. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences of RACF managers in preparing to respond to the pandemic will better inform practice development in aged care in particular the use of telehealth and safe practices during COVID-19. Increased awareness of the challenges faced by RACFs during a pandemic provides policymakers with valuable insights for future planning of pandemic responses.

The effects of education levels of developmental care in Australia: Perceptions and challenges.

BACKGROUND: Developmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention. AIMS AND OBJECTIVES: The objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care. DESIGN: This involves a cross-sectional survey design. METHODS: An online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys. RESULTS: Differences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2-1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9-6.2] and [OR: 2.1, 95% CI: 0.6-7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3-9.9) than metropolitan respondents. CONCLUSION: The application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

PACE-IT study protocol: a stepped wedge cluster randomised controlled trial evaluating the implementation of telehealth visual assessment in emergency care for people living in residential aged-care facilities.

BACKGROUND: Transfer of residential aged-care facility (RACF) residents to Emergency Departments (ED) is common, risky and expensive. RACF residents who present to ED are more likely to have hospital readmissions, longer stays and face major risks related to hospital acquired complications. Aged Care Emergency services (ACE) is a nurse led, protocol- guided, telephone RACF/ED outreach model that has been shown to be effective in reducing hospitalisation and length of hospital stay for RACF residents in the Hunter New England Local Health District, New South Wales (NSW). The Partnerships in Aged-Care Emergency services using Interactive Telehealth (PACE-IT) project enhances ACE by incorporating interactive video assessment and consultation. The PACE-IT project's primary aim is to assess whether augmentation of ACE services through the addition of protocol-guided interactive Visual Telehealth Consultation (VTC) for clinical decision-making, plus telephone follow-up, reduces RACF resident transfers to ED. METHODS: A stepped-wedge cluster randomised controlled trial will be conducted. The intervention will be delivered sequentially to 8 clusters; each cluster comprises one ED and two RACFs in NSW, Australia. The 16 RACFs in the study will be selected for order of implementation using a computer-generated randomisation sequence. A 2-step randomisation process will be undertaken, randomising the hospital EDs first and then randomising the RACFs aligned with each hospital. The PACE-IT intervention comprises: an initial phone call by RACFs to the ACE service in the ED; the ACE service in ED responds with a protocol-guided VTC, a management plan agreed between all participants; an automated consultation summary letter to the General Practitioner and the RACF; a post VTC 24 h follow-up phone call to the RACF. DISCUSSION: If shown to be effective, the intervention has the potential to improve the clinical care and quality of life for residents. Findings will provide high level evidence that will inform sustainable change and broad translation into practice across NSW. It will show how the change has been achieved and highlight success factors for scalability and sustainability. It will inform review of processes, the development of policy and guidelines that will integrate PACE-IT into existing service models in NSW. TRIAL REGISTRATION: The trial is registered with the Australian New Zealand Clinical Trials Registry (Trial ID ACTR N12619001692123 ) 02/12/2020.).

Fractional exhaled nitric oxide-based asthma management: The feasibility of its implementation into antenatal care in New South Wales, Australia.

BACKGROUND: The use of fractional exhaled nitric oxide (FeNO)-based asthma management during pregnancy can significantly reduce asthma exacerbations in non-smoking pregnant women. The feasibility of implementing this strategy into antenatal care has not been explored. AIMS: To examine the feasibility of implementing FeNO-based asthma management into antenatal clinics in New South Wales (NSW) Australia. MATERIALS AND METHODS: Semi-structured face-to-face interviews with video elicitation were conducted with healthcare professionals (HCPs) providing antenatal care in one of two hospital-based antenatal clinics in NSW, Australia. The video shown demonstrated the use of the FeNO instrument and other aspects of the management strategy, in antenatal care. Interviews were recorded, transcribed and analysed using qualitative content analysis. RESULTS: A total of 20 interviews were conducted with 15 midwives, four obstetricians, and one general practitioner. Two main themes and ten sub-themes arose: Getting a number (sub-themes: engaging, technically easy, objective, predictive, reassuring); and Resourcing (sub-themes: time and timing, systems, staff, education and cost). Comments included: 'It's easy, fast and effective' and 'the main barrier is time'. All HCPs felt capable of facilitating the FeNO-based management strategy, with appropriate education, and were willing to undertake this strategy, saying: '…it would be perfectly acceptable for a midwife or doctor to do it'; also, 'they don't necessarily need to see a physician, it's something that midwives would take on generally…'. CONCLUSION: Participants in this study considered FeNO-based asthma management for pregnant women to be a feasible addition to antenatal care following appropriate provision of resources and education.

Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre- and postintervention study.

AIMS AND OBJECTIVES: This study aimed to reduce indwelling urinary catheter (IDC) use and duration through implementation of a multifaceted "bundled" care intervention. BACKGROUND: Indwelling urinary catheters present a risk for patients through the potential development of catheter-associated urinary tract infection (CAUTI), with duration of IDC a key risk factor. Catheter-associated urinary tract infection is considered preventable yet accounts for over a third of all hospital-acquired infections. The most effective CAUTI reduction strategy is to avoid IDC use where ever possible and to remove the IDC as early as appropriate. DESIGN: A cluster-controlled pre- and poststudy at a facility level with a phased intervention implementation approach. METHODS: A multifaceted intervention involving a "No CAUTI" catheter care bundle was implemented, in 4 acute-care hospitals, 2 in metropolitan and 2 in rural locations, in New South Wales, Australia. Indwelling urinary catheter point prevalence and duration data were collected at the bedside on 1,630 adult inpatients at preintervention and 1,677 and 1,551 at 4 and 9 months postintervention. This study is presented in line with the StaRI checklist (see Appendix S1). RESULTS: A nonsignificant trend towards reduction in IDC prevalence was identified, from 12% preintervention to 10% of all inpatients at 4 and 9 months. Variability in preintervention IDC prevalence existed across hospitals (8%-16%). Variability in reduction was evident across hospitals at 4 months (between -2% and 4%) and 9 months (between 0%-8%). Hospitals with higher preintervention prevalence showed larger decreases, up to 50% when preintervention prevalence was 16%. Indwelling urinary catheter duration increased as more of the short-term IDC placements were avoided. CONCLUSIONS: Implementation of a multifaceted intervention resulted in reduced IDC use in four acute-care hospitals in Australia. This result was not statistically significant but did reflect a positive trend of reduction. There was a significant reduction in short-term IDC use at 9 months postintervention. RELEVANCE TO CLINICAL PRACTICE: Clinical nurse leaders can effectively implement change strategies that influence patient outcomes. Implementation of the evidence-based "No CAUTI" bundle increased awareness of appropriate indications and provided nurses with the tools to inform decision-making related to insertion and removal of IDCs in acute inpatient settings. Working in partnership with inpatients and the multidisciplinary team is essential in minimising acute-care IDC use.

Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012.

BACKGROUND: In New South Wales (NSW) Australia, women at low risk of complications can choose from three birth settings: home, birth centre and hospital. Between 2000 and 2012, around 6.4% of pregnant women planned to give birth in a birth centre (6%) or at home (0.4%) and 93.6% of women planned to birth in a hospital. A proportion of the woman in the home and birth centre groups transferred to hospital. However, their pathways or trajectories are largely unknown. AIM: The aim was to map the trajectories and interventions experienced by women and their babies from births planned at home, in a birth centre or in a hospital over a 13-year period in NSW. METHODS: Using population-based linked datasets from NSW, women at low risk of complications, with singleton pregnancies, gestation 37-41 completed weeks and spontaneous onset of labour were included. We used a decision tree framework to depict the trajectories of these women and estimate the probabilities of the following: giving birth in their planned setting; being transferred; requiring interventions and neonatal admission to higher level hospital care. The trajectories were analysed by parity. RESULTS: Over a 13-year period, 23% of nulliparous and 0.8% of multiparous women planning a home birth were transferred to hospital. In the birth centre group, 34% of nulliparae and 12% of multiparas were transferred to a hospital. Normal vaginal birth rates were higher in multiparous women compared to nulliparous women in all settings. Neonatal admission to SCN/NICU was highest in the planned hospital group for nulliparous women (10.1%), 7.1% for nulliparous women planning a birth centre birth and 5.1% of nulliparous women planning a homebirth. Multiparas had lower admissions to SCN/NICU for all thee settings (hospital 6.3%, BC 3.6%, home 1.6%, respectively). CONCLUSIONS: Women who plan to give birth at home or in a birth centre have high rates of vaginal birth, even when transferred to hospital. Evidence on the trajectories of women who choose to give birth at home or in birth centres will assist the planning, costing and expansion of models of care in NSW.

Labour outcomes in caseload midwifery and standard care: a register-based cohort study.

BACKGROUND: Research on caseload midwifery in a Danish setting is missing. This cohort study aimed to compare labour outcomes in caseload midwifery and standard midwifery care. METHODS: A historical register-based cohort study was carried out using routinely collected data about all singleton births 2013-2016 in two maternity units in the North Denmark Region. In this region, women are geographically allocated to caseload midwifery or standard care, as caseload midwifery is only available in some towns in the peripheral part of the uptake areas of the maternity units, and it is the only model of care offered here. Labour outcomes of 2679 all-risk women in caseload midwifery were compared with those of 10,436 all-risk women in standard midwifery care using multivariate linear and logistic regression analyses. RESULTS: Compared to women in standard care, augmentation was more frequent in caseload women (adjusted odds ratio (aOR) 1.20; 95% CI 1.06-1.35) as was labour duration of less than 10 h (aOR 1.26; 95% CI 1.13-1.42). More emergency caesarean sections were observed in caseload women (aOR 1.17; 95% CI 1.03-1.34), but this might partly be explained by longer distance to the maternity unit in caseload women. When caseload women were compared to women in standard care with a similar long distance to the hospital, no difference in emergency caesarean sections was observed (aOR 1.04; 95% CI 0.84-1.28). Compared to standard care, infants of caseload women more often had Apgar ≤7 after 5 min. (aOR 1.57; 95% CI 1.11-2.23) and this difference remained when caseload women were compared to women with similar distance to the hospital. For elective caesarean sections, preterm birth, induction of labour, dilatation of cervix on admission, amniotomy, epidural analgesia, and instrumental deliveries, we did not obseve any differences between the two groups. After birth, caseload women more often experienced no laceration (aOR 1.17; 95% CI 1.06-1.29). CONCLUSIONS: For most labour outcomes, there were no differences across the two models of midwifery-led care but unexpectedly, we observed slightly more augmentation and adverse neonatal outcomes in caseload midwifery. These findings should be interpreted in the context of the overall low intervention and complication rates in this Danish setting and in the context of research that supports the benefits of caseload midwifery. Although the observational design of the study allows only cautious conclusions, this study highlights the importance of monitoring and evaluating new practices contextually.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child.

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Weighing as a stand-alone intervention does not reduce excessive gestational weight gain compared to routine antenatal care: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Excessive gestational weight gain is associated with short and long-term adverse maternal and infant health outcomes, independent of pre-pregnancy body mass index. Weighing pregnant women as a stand-alone intervention during antenatal visits is suggested to reduce pregnancy weight gain. In the absence of effective interventions to reduce excessive gestational gain within the real world setting, this study aims to test if routine weighing as a stand-alone intervention can reduce total pregnancy weight gain and, in particular, excessive gestational weight gain. METHODS: A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted between November 2014 and January 2016, and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Seven databases were searched. A priori eligibility criteria were applied to published literature by at least two independent reviewers. Studies considered methodologically rigorous, as per the Academy of Nutrition and Dietetics Quality Criteria Checklist for Primary Research, were included. Meta-analysis was conducted using fixed-effects models. RESULTS: A total of 5223 (non-duplicated) records were screened, resulting in two RCTs that were pooled for meta-analysis (n = 1068 randomised participants; n = 538 intervention, n = 534 control). No difference in total weight gain per week was observed between intervention and control groups (weighted mean difference (WMD) -0.00 kg/week, 95% confidence interval (CI) -0.03 to 0.02). There was also no reduction in excessive gestational weight gain between intervention and control, according to pre-pregnancy body mass index (BMI). However, total weight gain was lower in underweight women (n = 23, BMI <18.5 kg/m2) in the intervention compared to control group (-0.12 kg/week, 95% CI -0.23 to -0.01). No significant differences were observed for other pregnancy, birth and infant outcomes. CONCLUSION: Weighing as a stand-alone intervention is not worse nor better at reducing excessive gestational weight gain than routine antenatal care.

Using video in childbirth research.

BACKGROUND: Conducting video-research in birth settings raises challenges for ethics review boards to view birthing women and research-midwives as capable, autonomous decision-makers. AIM: This study aimed to gain an understanding of how the ethical approval process was experienced and to chronicle the perceived risks and benefits. RESEARCH DESIGN: The Birth Unit Design project was a 2012 Australian ethnographic study that used video recording to investigate the physical design features in the hospital birthing space that might influence both verbal and non-verbal communication and the experiences of childbearing women, midwives and supporters. Participants and research context: Six women, 11 midwives and 11 childbirth supporters were filmed during the women's labours in hospital birth units and interviewed 6 weeks later. Ethical considerations: The study was approved by an Australian Health Research Ethics Committee after a protracted process of negotiation. FINDINGS: The ethics committee was influenced by a traditional view of research as based on scientific experiments resulting in a poor understanding of video-ethnographic research, a paradigmatic view of the politics and practicalities of modern childbirth processes, a desire to protect institutions from litigation, and what we perceived as a paternalistic approach towards protecting participants, one that was at odds with our aim to facilitate situations in which women could make flexible, autonomous decisions about how they might engage with the research process. DISCUSSION: The perceived need for protection was overly burdensome and against the wishes of the participants themselves; ultimately, this limited the capacity of the study to improve care for women and babies. CONCLUSION: Recommendations are offered for those involved in ethical approval processes for qualitative research in childbirth settings. The complexity of issues within childbirth settings, as in most modern healthcare settings, should be analysed using a variety of research approaches, beyond efficacy-style randomised controlled trials, to expand and improve practice-based results.

A methodological review of qualitative case study methodology in midwifery research.

AIM: To explore the use and application of case study research in midwifery. BACKGROUND: Case study research provides rich data for the analysis of complex issues and interventions in the healthcare disciplines; however, a gap in the midwifery research literature was identified. DESIGN: A methodological review of midwifery case study research using recognized templates, frameworks and reporting guidelines facilitated comprehensive analysis. DATA SOURCES: An electronic database search using the date range January 2005-December 2014: Maternal and Infant Care, CINAHL Plus, Academic Search Complete, Web of Knowledge, SCOPUS, Medline, Health Collection (Informit), Cochrane Library Health Source: Nursing/Academic Edition, Wiley online and ProQuest Central. REVIEW METHODS: Narrative evaluation was undertaken. Clearly worded questions reflected the problem and purpose. The application, strengths and limitations of case study methods were identified through a quality appraisal process. RESULTS: The review identified both case study research's applicability to midwifery and its low uptake, especially in clinical studies. Many papers included the necessary criteria to achieve rigour. The included measures of authenticity and methodology were varied. A high standard of authenticity was observed, suggesting authors considered these elements to be routine inclusions. Technical aspects were lacking in many papers, namely a lack of reflexivity and incomplete transparency of processes. CONCLUSION: This review raises the profile of case study research in midwifery. Midwives will be encouraged to explore if case study research is suitable for their investigation. The raised profile will demonstrate further applicability; encourage support and wider adoption in the midwifery setting.