Comparison of Spontaneous Pushing and Directed Pushing During the Second Stage of Labor Among Chinese Women Without Epidural Analgesia: Protocol for a Noninferior Feasibility Study.

BACKGROUND: Maternal pushing during the second stage of labor could influence labor progress and maternal-neonatal outcomes. Although the image of health care providers directing the laboring women to push during the second stage of labor could be commonly observed globally, this practice is not sufficiently researched and is questioned regarding its effectiveness and outcomes on the mother and baby. Meanwhile, a strategy referred to as "spontaneous pushing," which supports women to push by following their bodily urges, has been evaluated in several trials. However, in China, spontaneous pushing is not common practice. Notwithstanding the evaluation of spontaneous pushing, there is a lack of high-quality evidence to support either strategies of directed pushing or spontaneous pushing. OBJECTIVE: This study aims to test the feasibility of a future randomized controlled trial to compare the effects of spontaneous pushing and directed pushing during the second stage of labor for maternal and neonatal outcomes in China. METHODS: A nonrandomized, single-group, noninferiority feasibility study will be conducted in a public hospital in Hebei Province, China. In total, 105 women meeting the selection criteria will be recruited to receive the intervention (spontaneous pushing), while 105 sets of medical notes from women who received routine care (directed pushing) will be identified and reviewed to compare outcomes for both cohorts. A mixed methods approach will be used to assess primary outcomes (feasibility and acceptability) and secondary outcomes (effectiveness). RESULTS: Data collection took place between May and October 2023. A total of 110 women were invited to participate in the intervention of spontaneous pushing. Midwives' interviews were conducted and will be transcribed for analysis in March 2024. The data analysis is planned to be completed by May 2024. CONCLUSIONS: This feasibility study will provide important information by conducting a full-scale clinical trial in the future as well as the potential facilitators and barriers of it. A future randomized controlled trial is likely to have considerable policy and funding impacts regarding pushing management during the second stage of labor and improvement in women's childbirth experience. TRIAL REGISTRATION: Chinese Clinical Trial Register ChiCTR2300071178; https://tinyurl.com/mudtnbft. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55701.

Health care providers' perspectives on the mistreatment towards women during maternity care: Do perceptions of the working environment and empathy level matter?

BACKGROUND: Mistreatment of women in maternity care violates human rights, erodes trust and disrupts the continuity of maternal healthcare services. Investigating Health Care Providers' (HCPs) perspectives is indispensable in uncovering drivers and designing targeted interventions. AIM: To identify the roles of HCPs' perceptions of the working environment and levels of empathy on the mistreatment of women during maternity care. METHODS: We conducted a self-administered survey among 148 maternal HCPs practising in ten health centres and four hospitals in the East Wollega Zone, Western Ethiopia, from June to September 2022. FINDINGS: Most providers reported seeing other HCPs mistreating women (93.2%), while three-fourths (75.7%) admitted it as their actions. Violation of privacy and confidentiality was the most frequently reported category of mistreatment (44.6%), followed by physical abuse (37.1%) and verbal abuse (35.8%). The likelihood of mistreating women was reduced by 65% (AOR=0.35, 95% CI: [0.14, 0.86]) among individuals with positive perceptions of their working environment compared to those with negative perceptions. A unit increase in providers' empathy also led to a five per cent decrease in mistreatment (AOR=0.95, 95% CI: [0.91, 0.98]. CONCLUSIONS: HCPs' perceptions of their working environment and enhanced empathy levels were associated with the reduction of the odds of mistreatment of women. While empathic care should be cultivated as a component of HCPs' competencies, efforts should be made to improve the conditions of the demanding health system to realise a resilient, motivated, competent, and compassionate workforce. The interplay between gender, profession, and mistreatment level requires further investigation.

The mistreatment of women during maternity care and its association with the maternal continuum of care in health facilities.

BACKGROUND: Mistreatment of childbearing women continues despite global attention to respectful care. In Ethiopia, although there have been reports of mistreatment of women during maternity care, the influence of this mistreatment on the continuum of maternity care remains unclear. In this paper, we report the prevalence of mistreatment of women from various dimensions, factors related to mistreatment and also its association to the continuum of maternity care in health facilities. METHODS: We conducted an institution-based cross-sectional survey among women who gave birth within three months before the data collection period in Western Ethiopia. A total of 760 women participated in a survey conducted face-to-face at five health facilities during child immunization visits. Using a validated survey tool, we assessed mistreatment in four categories and employed a mixed-effects logistic regression model to identify its predictors and its association with the continuum of maternity care, presenting results as adjusted odds ratios (AORs) with their 95% confidence intervals (CIs). RESULTS: Over a third of women (37.4%) experienced interpersonal abuse, 29.9% received substandard care, 50.9% had poor interactions with healthcare providers, and 6.2% faced health system constraints. The odds of mistreatment were higher among women from the lowest economic status, gave birth vaginally and those who encountered complications during pregnancy or birth, while having a companion of choice during maternity care was associated to reduced odds of mistreatment by 42% (AOR = 0.58, 95% CI: [0.42-0.81]). Women who experienced physical abuse, verbal abuse, stigma, or discrimination during maternity care had a significantly reduced likelihood of completing the continuum of care, with their odds decreased by half compared to those who did not face such interpersonal abuse (AOR = 0.49, 95% CI: [0.29-0.83]). CONCLUSIONS: Mistreatment of women was found to be a pervasive problem that extends beyond labour and birth, it negatively affects upon maternal continuum of care. Addressing this issue requires an effort to prevent mistreatment through attitude and value transformation trainings. Such interventions should align with a system level actions, including enforcing respectful care as a competency, enhancing health centre functionality, improving the referral system, and influencing communities to demand respectful care.

What do women in Australia want from their maternity care: A scoping review.

BACKGROUND: Just over 300,000 women give birth in Australia each year. It is important for health care providers, managers, and policy makers know what women want from their care so services can be provided appropriately. This review is a part of the Midwifery Futures Project, which aims to prepare the midwifery workforce to best address the needs of women. The aim of this review was to describe and analyse current literature on the maternity care needs of women in Australia. METHODS: A scoping review methodology was used, guided by the Joanna Briggs Institute framework. A systematic search of the literature identified 9023 studies, and 59 met inclusion criteria: being peer-reviewed research focusing on maternity care needs, conducted in Australian populations, from 2012 to 2023. The studies were analysed using inductive content analysis. RESULTS: Four themes were developed: Continuity of care, being seen and heard, being safe, and being enabled. Continuity of care, especially a desire for midwifery continuity of care, was the central theme, as it was a tool supporting women to be seen and heard, safe, and enabled. CONCLUSION: This review highlights that women in Australia consistently want access to midwifery continuity of care as an enabler for addressing their maternity care needs. Transforming Australian maternity care policy and service provision towards continuity would better meet women's needs.

"If Not Me, Then Who?": Exploring the Challenges Experienced by Front-Line Clinicians Screening for, and Communicating About, Domestic Violence in the Emergency Department.

Screening for domestic violence in healthcare settings increases detection. The emergency department (ED) is one setting where victims frequently attend with injuries and illnesses sustained from violence. However, screening rates remain suboptimal. There is little research about how formal screening occurs, or how less structured interactions are negotiated within the ED context. This article explores this important, but non-mandatory procedure within the context of clinician-patient interactions in Australia. A descriptive qualitative study was undertaken with 21 clinicians across seven EDs in Australia. Thematic analysis was undertaken by two researchers. Results indicate a lack of confidence around DV screening, and tensions in clinicians initiating conversation while managing their own emotional stressors. No participants expressed knowledge of formal screening processes in their workplaces. Successful DV screening programs must provide clinicians with the tools to minimize perceived discomfort in initiating and sustaining conversations while accepting patient preferences regarding disclosure.

The roles of multi-component interventions in reducing mistreatment of women and enhancing respectful maternity care: a systematic review.

BACKGROUND: Despite recognition of the adverse impacts of the mistreatment of women during pregnancy, labour and birth, there remains limited evidence on interventions that could reduce mistreatment and build a culture of respectful maternity care (RMC) in health facilities. The sustainability of effective individual interventions and their adaptability to various global contexts remain uncertain. In this systematic review, we aimed to synthesise the best available evidence that has been shown to be effective in reducing the mistreatment of women and/or enhancing RMC during women's maternity care in health facilities. METHODS: We searched the online databases PubMed, CINAHL, EBSCO Nursing/Academic Edition, Embase, African Journals Online (AJOL), Scopus, Web of Science, and grey literature using predetermined search strategies. We included cluster randomized controlled trials (RCTs) and pre-and-post observational studies and appraised them using JBI critical appraisal checklists. The findings were synthesised narratively without conducting a meta-analysis. The certainty of evidence was assessed using GRADE criteria. RESULTS: From the 1493 identified records, 11 studies from six sub-Sahara African countries and one study from India were included: three cluster RCTs and nine pre- and post-studies. We identified diverse interventions implemented via various approaches including individual health care providers, health systems, and policy amendments. Moderate certainty evidence from two cluster RCTs and four pre- and post-studies suggests that multi-component interventions can reduce the odds of mistreatment that women may experience in health facilities, with odds of reduction ranging from 18 per cent to 66 per cent. Similarly, women's perceptions of maternity care as respectful increased in moderate certainty evidence from two cluster RCTs and five pre- and post-studies with reported increases ranging from 5 per cent to 50 per cent. CONCLUSIONS: Multi-component interventions that address attitudes and behaviors of health care providers, motivate staff, engage the local community, and alleviate health facility and system constraints have been found to effectively reduce mistreatment of women and/or increase respectful maternity care. Such interventions which go beyond a single focus like staff training appear to be more likely to bring about change. Therefore, future interventions should consider diverse approaches that incorporate these components to improve maternal care.

Midwife led randomised controlled trials in Australia and New Zealand: A scoping review.

BACKGROUND: Midwives are the largest workforce involved in caring for pregnant women and their babies, and are well placed to translate research into practice and ensure midwifery priorities are appropriately targeted in researched. Currently, the number and focus of randomised controlled trials led by midwives in Australia and New Zealand is unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established in 2020 to build nursing and midwifery research capacity. To aid this, scoping reviews of the quality and quantity of nurse and midwife led trials were undertaken. AIM: To identify midwife led trials conducted between 2000 and 2021 in Australia and New Zealand. METHODS: This review was informed by the JBI scoping review framework. Medline, Emcare, and Scopus were searched from 2000-August 2021. ANZCTR, NHMRC, MRFF, and HRC (NZ) registries were searched from inception to July 2021. FINDINGS: Of 26,467 randomised controlled trials registered on the Australian and New Zealand Clinical Trials Registry, 50 midwife led trials, and 35 peer-reviewed publications were identified. Publications were of moderate to high quality with scores limited due to an inability to blind participants or clinicians. Blinding of assessors was included in 19 published trials. DISCUSSION: Additional support for midwives to design and conduct trials and publish findings is required. Further support is needed to translate registration of trial protocols into peer reviewed publications. CONCLUSION: These findings will inform the Australasian Nursing and Midwifery Clinical Trials Network plans to promote quality midwife led trials.

Australian women's perspectives of routine enquiry into domestic violence before and after birth.

BACKGROUND: Peripartum women are vulnerable to experiencing intimate partner violence (IPV). Interactions with health practitioners during maternity care provide a unique opportunity to detect and respond to women who are experiencing IPV. The aim of this study was to explore women's experiences of IPV screening at an Australian maternity service. METHODS: Qualitative methodology was used in this cross-sectional study. In-depth semi-structured interviews were conducted with women with IPV who attended an Australian maternity service. Thematic analysis was used to identify codes and themes. RESULTS: The nine women expressed three major themes, and six sub-themes, surrounding clinician approaches (communication and support, asking about IPV, and following disclosure), system considerations (fear of child safety involvement, continuity of care, and environmental considerations), and education. All participants supported screening and highlighted beneficial or detrimental approaches to screening and care, and recommendations for improvement. CONCLUSION: This research points to the benefit of trauma-informed frameworks in hospitals to support women experiencing IPV.

Perinatal mental healthcare: Developing skills in midwifery students.

Midwives have a pivotal role in screening for risk factors for mental illness and psychosocial vulnerabilities in women during the perinatal period. They also have a key responsibility to provide women with the appropriate resources to support their mental wellbeing. Midwives can lack confidence and/or feelings of competence regarding these skills. Care of women in the context of their perinatal mental health is a core midwifery skill that deserves practical learning during pre-registration education, just as the more 'hands on' skills such as abdominal palpation, labour and birth support or newborn examination. However, there is limited opportunity for students to gain clinical placement experiences that are specific to perinatal mental health (PMH). This discussion paper describes an innovative teaching and learning project that aimed to improve confidence in students' ability to conduct screening, support, and referral of women experiencing mental ill health. The project involved the development of an Objective Structured Clinical Examination (OSCE) and audio visual resources to support learning and teaching and clinical placement. Feedback was collected to inform the refinement of the first OSCE, and to assist in the design of the audio visual resources that are now displayed publicly on the Australian College of Midwives website at https://www.midwives.org.au/Web/Web/Professional-Development/Resources.aspx?hkey=12c2360e-d8b9-4286-8d0a-50aeaeca9702.

Does midwifery continuity of care make a difference to women with perinatal mental health conditions: A cohort study, from Australia.

BACKGROUND: Perinatal mental health (PMH) conditions are associated with an increased risk of adverse perinatal outcomes including preterm birth. Midwifery caseload group practice (continuity of care, MCP) improves perinatal outcomes including a 24 % reduction of preterm birth. The evidence is unclear whether MCP has the same effect for women with perinatal mental health conditions. AIM: To compare perinatal outcomes in women with a mental health history between MCP and standard models of maternity care. The primary outcome measured the rates of preterm birth. METHODS: A retrospective cohort study using routinely collected data of women with PMH conditions between 1st January 2018 - 31st January 2021 was conducted. We compared characteristics and outcomes between groups. Multivariate logistic regression models were performed adjusting for a-priori selected variables and factors that differ between models of care. RESULTS: The cohort included 3028 women with PMH, 352 (11.6 %) received MCP. The most common diagnosis was anxiety and depression (n = 723, 23.9 %). Women receiving MCP were younger (mean 30.9 vs 31.3, p = 0.03), Caucasian (37.8 vs 27.1, p < 0.001), socio-economically advantaged (31.0 % vs 20.2, p < 0.001); less likely to smoke (5.1 vs 11.9, p < 0.001) and with lower BMI (mean 24.3 vs 26.5, p < 0.001) than those in the standard care group. Women in MCP had lower odds of preterm birth (adjOR 0.46, 95 % CI 0.24-0.86), higher odds of vaginal birth (adjOR 2.55, 95 % CI 1.93-3.36), breastfeeding at discharge (adj OR 3.06, 95 % CI 2.10-4.55) with no difference in severe adverse neonatal outcome (adj OR 0.79, 95 % CI 0.57-1.09). CONCLUSIONS: This evidence supports MCP for women with PMH. Future RCTs on model of care for this group of women is needed to establish causation.

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.

Improving domestic violence screening practices in the emergency department: an Australian perspective.

INTRODUCTION: Domestic violence (DV) is a major cause of morbidity worldwide. The ED is a location recommended for opportunistic screening. However, screening within EDs remains irregular. OBJECTIVE: To examine intrinsic and extrinsic barriers to routine screening in Australian EDs, while describing actions taken after identification of DV. METHODS: Emergency clinicians at nine public hospitals participated in an anonymous online survey. Factor analysis was performed to identify principal components around attitudes and beliefs towards screening. RESULTS: In total, 496 emergency clinicians participated. Universal screening was uncommon; less than 2% of respondents reported screening all adults or all women. Although willing, nearly half (45%) reported not knowing how to screen. High patient load and no single rooms were 'very or severely limiting' for 88% of respondents, respectively, while 24/7 social work and interpreter services, and online/written DV protocols were top enablers. Factor analysis identified four distinct intrinsic belief components: (1) screening is not futile and could be done in ED, (2) screening will not cause harm, (3) there is a duty to screen and (4) I am willing to screen. CONCLUSION: This study describes a culture of Queensland ED clinicians that believe DV screening in ED is important and interventions are effective. Most ED clinicians are willing to screen. In this setting, availability of social work and interpreter services are important mitigating resources. Clinician education focusing on duty to screen, coupled with a built-in screening tool, and e-links to a local management protocol may improve the uptake of screening and subsequently increase detection.

Domestic violence screening in a public mental health service: A qualitative examination of mental health clinician responses to DFV.

WHAT IS KNOWN ON THE SUBJECT?: Mental health clients experience higher estimated rates of domestic violence, yet mental health services are less likely to screen for domestic violence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper qualitatively explores the perspectives and experiences of mental health practitioners in inpatient and community teams in a publicly funded hospital and health service (i.e. public mental health service). Mental health practitioners described a lack of domestic violence training, as well as a lack of knowledge of domestic violence and support mechanisms for victims, when domestic violence is disclosed by clients. The paper highlights the unique difficulties and barriers experienced by clinicians in screening for domestic violence while also dealing with clients suffering a mental health crisis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The paper sheds more light on the issue of domestic violence in mental health in terms of screening, and identifies avenues for improvement in mental health services; particularly the need for staff training and education. ABSTRACT: Introduction Domestic violence is particularly prevalent within mental health client groups, though screening for domestic violence within mental health services is often overlooked. Aim To investigate the experiences and opinions of domestic violence screening by mental health clinicians in a publicly funded hospital and health service. Methods Semi-structured interviews were conducted with twelve clinicians working in publicly funded mental health services in Queensland, Australia. Transcripts were thematically analysed. Results Four main themes emerged from the data: staff training and experience; prioritizing domestic violence screening; attitudes to domestic violence; and victim support. Participants discussed a lack of training for, or expectations of, domestic violence screening in mental health services. They also highlighted a lack of resources enabling them to appropriately respond when domestic violence was identified. Discussion Education, attitudes and resources relating to domestic violence are major factors that should be addressed for the successful screening and treatment of clients in mental health. Implications for Practice This paper informs services of the gaps in knowledge and care around domestic violence and mental health. A less medicalized approach to the treatment of mental health should be adopted, and domestic violence training introduced for all healthcare practitioners, to improve client outcomes.

Tuberculosis control at a South African correctional centre: Diagnosis, treatment and strain characterisation.

BACKGROUND: Correctional centres provide ideal conditions for tuberculosis (TB) transmission and disease progression. Despite the high TB incidence and incarceration rate in South Africa, data from South African correctional centres are scarce. Thus, the study evaluated TB diagnosis, treatment initiation and completion, and identified prevalent Mycobacterium tuberculosis strains among detainees entering a South African correctional centre. METHODS: This study was a prospective observational study that enrolled participants between February and September 2017 from a correctional centre located in the Western Cape, South Africa. All adult male detainees who tested positive for TB during admission screening were eligible to participate in the study. Sputum samples from enrolled participants underwent smear microscopy and culture. Strain typing was performed on culture-positive samples. The time between specimen collection and diagnosis, the time between diagnosis and treatment initiation, and the proportion of detainees completing TB treatment at the correctional centre were calculated. RESULTS: During the study period, 130 TB cases were detected through routine admission screening (126 male, 2 female, 2 juvenile). Out of the 126 eligible male detainees, 102 were enrolled in the study (81%, 102/126). All TB cases were detected within 30 hrs of admission screening. The majority (78%, 80/102) of participants started treatment within 48 hrs of TB diagnosis. However, only 8% (9/102) of participants completed treatment at the correction centre. Sputa from 90 of the 102 participants were available for smear and culture. There was a high smear positivity, with 49% (44/90) of isolates being smear positive. The Beijing family was the most frequent lineage (55.2%) in the study. CONCLUSION: The strengths of the current TB control efforts at the correctional centre include rapid detection of cases through admission screening and prompt treatment initiation. However, a high number of detainees exiting before treatment completion highlights the need to strengthen links between correctional TB services and community TB services to ensure detainees complete TB treatment after release and prevent TB transmission.

What strategies facilitate & support the successful transition of newly qualified midwives into practice: An integrative literature review.

OBJECTIVE: The aim of this review was to identify strategies that facilitate newly qualified midwives to transition successfully from midwifery student to confident, competent practitioner. DESIGN: Integrative literature review. DATA SOURCES: The following databases were accessed: CINAHL complete, Medline complete, APA PsycINFO, Cochrane Library, Joanna Briggs Institute (JBI), Scopus and Google Scholar. REVIEW METHODS: A systematic search of key terms across all data sources for the period January 1990 to September 2021 identified 316 papers whose titles/abstracts were screened against our inclusion/exclusion criteria. Thirty-six full texts were screened for eligibility and three papers were identified through ancestral searching. Ten papers were included in our final review. RESULTS: Mentorship or preceptorship for newly qualified midwives by experienced midwives appears to enhance experiences, either as a standalone strategy, or component of structured programs of transition support. Supernumerary time, designated study days and planned rotations are also valued, particularly when rotating through clinical areas. Smaller teams providing continuity of midwifery care, or organisations that fund mentorship programs appear more able to facilitate support. Mechanisms of online support and learning may also enhance early transition but similarly, require organisational investment to aid success. Whilst most programs were described as helpful none of the studies used validated measures to assess this. CONCLUSION: Whilst elements of tailored support programs and mentoring/preceptorship from experienced colleagues appear to offer valuable support to transitioning practitioners, it is important to note that the structure of maternity care appears fundamental to the success of many of these strategies. Consequently, maternity care reform which focuses on the adoption of sustainable models of midwifery continuity, alongside urgent investment in midwives, are likely the most promising, over-arching strategies required to support student to midwife transition.

Benefits and risks of spontaneous pushing versus directed pushing during the second stage of labour among women without epidural analgesia: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to assess the benefits and risks of spontaneous pushing and directed pushing used by labouring women without epidural analgesia during the second stage labour. DESIGN: Systematic review and meta-analysis. METHODS: Randomised controlled trials published in PubMed/ MEDLINE, CINAHL, Web of Science, Scopus, EMBASE, psycINFO, the Cochrane Library, and four Chinese databases were systematically searched from their inception to December, 2021. Grey literature were also searched. Two authors independently screened the literature and evaluated the quality of the included studies. RESULTS: Ten studies with a total of 1510 women were pooled. Spontaneous pushing in the second stage of labour reduced the rates of Caesarean section and extended episiotomy. The difference was significant among spontaneous pushing group and directed pushing group, with relative risk and 95% confidence intervals of 0.42 and 0.19-0.94, 0.49 and 0.29-0.82, respectively. There was no significant difference in the duration of the second stage of labour, rates of spontaneous vaginal birth and newborn outcomes. CONCLUSION: The results of this meta-analysis demonstrate that spontaneous pushing during the second stage of labour results in at least the same maternal and newborn outcomes, lower Caesarean section rates and lower incidence of extended episiotomy.

Self-efficacy and social support as mediators of mental health among abused women.

Supportive counseling and facilitated referrals to support organizations have shown positive effects on mental health and coping with domestic and family violence. However, the reasons why and how such effects are significant remain unknown. The current paper used data from a randomized controlled trial of a psychosocial intervention implemented in Nepal among 140 abused pregnant women. The hypothesized mediating effects of self-efficacy and social support on mental health and quality of life of abused pregnant women were tested using serial mediation analyses. Significance of parameter estimates and bias-corrected 95% confidence intervals (CIs) for the indirect effects were generated using bootstrapping. The postintervention changes in self-efficacy and social support were found to have significant mediating effects on the relationship between the intervention and changes in both mental health and quality of life of participants post intervention. The positive effects on outcomes were seen at follow-up as well, though to a lesser extent. Further interventions should focus on enhancing abused women's self-efficacy and social support to ensure their positive mental health and better lives.

A qualitative study of early career Australian midwives' encounters with perinatal grief, loss and trauma.

PROBLEM: The health of women is dependent on midwifery workforce stability. Retaining new midwives is paramount, however without support, the early career can be a vulnerable time for midwives. BACKGROUND: Midwives care for women who experience poor perinatal outcomes like stillbirth and neonatal death. Midwifery care in these sentinel events is complex. There is limited understanding of early career midwives' experiences within these encounters. AIM: To understand the experiences of Australian early career midwives' clinical encounters with perinatal grief, loss and trauma. METHODS: A qualitative descriptive/exploratory study using in-depth interviews. FINDINGS: Four themes were identified from interview data: (1) all eyes on the skills; (2) support is of the essence; (3) enduring an emotional toll; (4) at all times, the woman. Most participants had minimal exposure to perinatal loss as a student. As a result, most felt unskilled and unprepared for this as a new midwife. DISCUSSION: Types and degrees of support varied in these encounters. Early career midwives who were well supported reflected positively on working with grief and loss. In contrast, inadequate or absent support had detrimental effects on participant wellbeing. Poorly supported encounters with death (intrapartum fetal, early neonatal, and maternal) in the early career period were significantly distressful, giving rise to mental and emotional distress. CONCLUSION: Pre-registration perinatal loss skill development and supported experiences are necessary for preparedness. Continued education, formalised debriefing and mentoring, institutional philosophies which promote collegial ethics of care, and the expansion of continuity of midwifery care models will improve new midwives' experiences.