Does health voucher intervention increase antenatal consultations and skilled birth attendances in Cameroon? Results from an interrupted time series analysis.

BACKGROUND: Limited access to health services during the antenatal period and during childbirth, due to financial barriers, is an obstacle to reducing maternal and child mortality. To improve the use of health services in the three regions of Cameroon, which have the worst reproductive, maternal, neonatal, child and adolescent health indicators, a health voucher project aiming to reduce financial barriers has been progressively implemented since 2015 in these three regions. Our research aimed to assess the impact of the voucher scheme on first antenatal consultation (ANC) and skilled birth attendance (SBA). METHODS: Routine aggregated data by month over the period January 2013 to May 2018 for each of the 33 and 37 health facilities included in the study sample were used to measure the effect of the voucher project on the first ANC and SBA, respectively. We estimated changes attributable to the intervention in terms of the levels of outcome indicators immediately after the start of the project and over time using an interrupted time series regression. A meta-analysis was used to obtain the overall estimates. RESULTS: Overall, the voucher project contributed to an immediate and statistically significant increase, one month after the start of the project, in the monthly number of ANCs (by 26%) and the monthly number of SBAs (by 57%). Compared to the period before the start of the project, a statistically significant monthly increase was observed during the project implementation for SBAs but not for the first ANCs. The results at the level of health facilities (HFs) were mixed. Some HFs experienced an improvement, while others were faced with the status quo or a decrease. CONCLUSIONS: Unlike SBAs, the voucher project in Cameroon had mixed results in improving first ANCs. These limited effects were likely the consequence of poor design and implementation challenges.

Challenges and opportunities of English as the medium of instruction in diploma midwifery programs in Bangladesh: a mixed-methods study.

BACKGROUND: English is generally recognized as the international language of science and most research on evidence-based medicine is produced in English. While Bangla is the dominant language in Bangladesh, public midwifery degree programs use English as the medium of instruction (EMI). This enables faculty and student access to the latest evidence-based midwifery content, which is essential for provision of quality care later. Yet, it also poses a barrier, as limited English mastery among students and faculty limits both teaching and learning. METHODS: This mixed-methods study investigates the challenges and opportunities associated with the implementation of EMI in the context of diploma midwifery education in Bangladesh. Surveys were sent to principals at 38 public midwifery education institutions, and 14 English instructors at those schools. Additionally, ten key informant interviews were held with select knowledgeable stakeholders with key themes identified. RESULTS: Surveys found that English instructors are primarily guest lecturers, trained in general or business English, without a standardized curriculum or functional English language laboratories. Three themes were identified in the key informant interviews. First, in addition to students' challenges with English, faculty mastery of English presented challenges as well. Second, language labs were poorly maintained, often non-functional, and lacked faculty. Third, an alternative education model, such as the English for Specific Purposes (ESP) curriculum,  has potential to strengthen English competencies within midwifery schools. CONCLUSIONS: ESP, which teaches English for application in a specific discipline, is one option available in Bangladesh for midwifery education. Native language instruction and the middle ground of multilingualism are also useful options. Although a major undertaking, investing in an ESP model and translation of technical midwifery content into relevant mother tongues may provide faster and more complete learning. In addition, a tiered system of requirements for English competencies tied to higher levels of midwifery education could build bridges to students to help them access global evidence-based care resources. Higher levels might emphasize English more heavily, while the diploma level would follow a multilingualism approach, teach using an ESP curriculum, and have complementary emphasis on the mother tongue.

Status of the midwifery workforce and childbirth services and the impact of midwife staffing on birth outcomes in China: a multicentre cross-sectional study.

OBJECTIVE: To investigate the status of the midwifery workforce and childbirth services in China and to identify the association between midwife staffing and childbirth outcomes. DESIGN: A descriptive, multicentre cross-sectional survey. SETTING: Maternity hospitals from the eastern, central and western regions of China. PARTICIPANTS: Stratified sampling of maternity hospitals between 1 July and 31 December 2021.The sample hospitals received a package of questionnaires, and the head midwives from the participating hospitals were invited to fill in the questionnaires. RESULTS: A total of 180 hospitals were selected and investigated, staffed with 4159 midwives, 412 obstetric nurses and 1007 obstetricians at the labour and delivery units. The average efficiency index of annual midwifery services was 272 deliveries per midwife. In the sample hospitals, 44.9% of women had a caesarean delivery and 21.4% had an episiotomy. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery (adjusted ß -0.032, 95% CI -0.115 to -0.012, p<0.05) and episiotomy (adjusted ß -0.171, 95% CI -0.190 to -0.056, p<0.001). CONCLUSION: The rates of childbirth interventions including the overall caesarean section in China and the episiotomy rate, especially in the central region, remain relatively high. Improved midwife staffing was associated with reduced rates of instrumental vaginal delivery and episiotomy, indicating that further investments in the midwifery workforce could produce better childbirth outcomes.

Evaluation of the feasibility of a midwifery educator continuous professional development (CPD) programme in Kenya and Nigeria: a mixed methods study.

BACKGROUND: Midwifery education is under-invested in developing countries with limited opportunities for midwifery educators to improve/maintain their core professional competencies. To improve the quality of midwifery education and capacity for educators to update their competencies, a blended midwifery educator-specific continuous professional development (CPD) programme was designed with key stakeholders. This study evaluated the feasibility of this programme in Kenya and Nigeria. METHODS: This was a mixed methods intervention study using a concurrent nested design. 120 randomly selected midwifery educators from 81 pre-service training institutions were recruited. Educators completed four self-directed online learning (SDL) modules and three-day practical training of the blended CPD programme on teaching methods (theory and clinical skills), assessments, effective feedback and digital innovations in teaching and learning. Pre- and post-training knowledge using multiple choice questions in SDL; confidence (on a 0-4 Likert scale) and practical skills in preparing a teaching a plan and microteaching (against a checklist) were measured. Differences in knowledge, confidence and skills were analysed. Participants' reaction to the programme (relevance and satisfaction assessed on a 0-4 Likert scale, what they liked and challenges) were collected. Key informant interviews with nursing and midwifery councils and institutions' managers were conducted. Thematic framework analysis was conducted for qualitative data. RESULTS: 116 (96.7%) and 108 (90%) educators completed the SDL and practical components respectively. Mean knowledge scores in SDL modules improved from 52.4% (± 10.4) to 80.4% (± 8.1), preparing teaching plan median scores improved from 63.6% (IQR 45.5) to 81.8% (IQR 27.3), and confidence in applying selected pedagogy skills improved from 2.7 to 3.7, p < 0.001. Participants rated the SDL and practical components of the programme high for relevance and satisfaction (median, 4 out of 4 for both). After training, 51.4% and 57.9% of the participants scored 75% or higher in preparing teaching plans and microteaching assessments. Country, training institution type or educator characteristics had no significant associations with overall competence in preparing teaching plans and microteaching (p > 0.05). Qualitatively, educators found the programme educative, flexible, convenient, motivating, and interactive for learning. Internet connectivity, computer technology, costs and time constraints were potential challenges to completing the programme. CONCLUSION: The programme was feasible and effective in improving the knowledge and skills of educators for effective teaching/learning. For successful roll-out, policy framework for mandatory midwifery educator specific CPD programme is needed.

Stress perception, coping behaviors and work-privacy conflict of student midwives in times of COVID-19 pandemic: the "Healthy MidStudents" study in Germany.

BACKGROUND: Student midwives deliver care for women under challenging job demands, which may affect their mental health- thus creating a high need for health promotion. Given the lack of research addressing this topic, the aim of this study is to examine the links between stress perception, coping behaviors, work-privacy conflict, and perception of COVID-19 pandemic impact on studies of student midwives in northern Germany. METHODS: Data were collected using a cross-sectional online-survey at nine midwifery study sites in northern Germany from October 2022 to January 2023. 342 student midwives (response rate: 61.3%) were surveyed on stress perception, coping behaviors, work-privacy conflict, and perceived impact of the COVID-19 pandemic on their studies. Descriptive, linear regression and moderation analyses were run to test explorative assumptions. RESULTS: Results revealed that higher levels of perceived stress were reported by 13.4% of student midwives. Social support (M = 13.76, SD = 2.19) and active stress coping (M = 10.72, SD = 2.01) were identified as most prevalent coping behaviors in the present sample. It was found that work-privacy conflict was positively associated with stress perception (ß = 0.53, p =.001) and maladaptive coping behaviors (alcohol and cigarette consumption: ß = 0.14, p =.015), and negatively associated with adaptive coping behaviors (positive thinking: ß = - 0.25, p =.001, social support: ß = - 0.23, p =.001). Students with children reported significantly lower levels of social support than students without children. 55.6% of student midwives perceived a negative impact of the COVID-19 pandemic on their studies (mostly on lectures, seminars, and contact with fellow students). CONCLUSIONS: Key findings highlighted moderate stress levels among student midwives during theoretical study stage. Based on current research, prevalence of high stress levels among student midwives remains unclear. Given the overall heterogeneous, limited research on student midwives' stress perception, coping behaviors, work-privacy conflict and perceptions of COVID-19 pandemic impact on studies, implications for research are suggested, e.g. longitudinal studies at different time points and settings and interventional studies. Findings provide a starting point for implementation of workplace health promotion in theoretical and practical stages of midwifery science study programs, e.g. training courses on stress prevention and adaptive coping, and for improvement of working conditions.

Knowledge of female genital schistosomiasis and urinary schistosomiasis among final-year midwifery students in the Volta Region of Ghana.

BACKGROUND: Female genital schistosomiasis (FGS) is a gynaecological complication of urinary schistosomiasis (US) with an estimated burden of 20-120 million cases in endemic areas. A neglected sexual and reproductive health disease in sub-Saharan Africa, FGS increases susceptibility to sexually transmitted infections including cervical cancer and infertility among other morbidities. However, there appears to be limited FGS knowledge among practicing and pre-service health providers with implications for control. We assessed FGS awareness among final-year midwifery students who would soon be delivering primary maternal and reproductive health care. METHODS: A cross-sectional study was conducted among 193 randomly selected final-year students from all three midwifery training institutions in the Volta region of Ghana in August/September, 2022. Data on participants' demographics and knowledge of the transmission, signs and symptoms, complications, treatment and prevention of both FGS and US were collected using structured questionnaires. Summary statistics were presented as frequencies, proportions and percentages. RESULTS: Only 23.3% (44/189) of participants had heard about FGS compared to 64% (123/192) for US. Of the former, 42 (95%), 40 (91%) and 36 (81.8%) respectively identified genital itching/burning sensation, bloody vaginal discharge and pelvic pain/pain during intercourse as part of the symptoms of FGS. Less than a third (13/44) and about half (25/44) of those who indicated hearing about FGS knew it can be a risk for ectopic pregnancies and infertility respectively. Majority of these participants, 40 (91%), wrongly selected antibiotics as treatment for FGS while 9 indicated it is prevented by sleeping in insecticide-treated nets. CONCLUSION: Awareness of FGS was limited among the study participants. The high prevalence of knowledge of some FGS symptoms related to the genitalia needs cautious interpretation. Health care training institutions must make deliberate efforts to highlight FGS in the training of midwives as the condition has diagnostic and management implications for some sexual and reproductive health conditions.

Health System and Individual Barriers to Supporting Healthy Gestational Weight Gain and Nutrition: A Qualitative Study of the Experiences of Midwives and Obstetricians in Publicly Funded Antenatal Care in Tasmania, Australia.

Individual and health system barriers can impede clinicians from supporting weight-related behaviour change for pregnant women, particularly in publicly funded antenatal care accessed by women from diverse socioeconomic backgrounds. The aim was to understand clinicians' experiences of supporting healthy gestational weight gain for pregnant women in a publicly funded antenatal setting. The work was undertaken to guide the implementation of systems changes, resource development, and workforce capacity building related to nutrition, physical activity, and gestational weight gain in the service. The qualitative descriptive study used purposive sampling and semi-structured interviews conducted between October 2019 and February 2020. Nine midwives and five obstetricians from a publicly funded hospital antenatal service in Tasmania, Australia participated. Interview transcripts were analysed using inductive thematic analysis. The three dominant themes were prioritising immediate needs, continuity of care support weight-related conversations, and limited service capacity for weight- and nutrition-related support. The subthemes were different practices for women according to weight and the need for appropriately tailored resources. Improving access to continuity of care and clinician training, and providing resources that appropriately consider women's socioeconomic circumstances and health literacy would enhance the ability and opportunities for clinicians to better support all women.

Feelings and thoughts of midwifery students during their first birth suite placement: A qualitative study.

This descriptive qualitative study aimed to understand the feelings and thoughts experienced by 4th year midwifery students during the first birth they attended during clinical practice. Focus group interviews were conducted with 22 final year midwifery students in Istanbul, Türkiye December 2020. The transcribed data were analyzed by the descriptive qualitative analysis method. The students experienced not only negative feelings such as fear, torment, anxiety but also positive feelings such as hope, excitement, and curiosity during the first birth practice. The situations that caused negative feelings and thoughts were not only the feelings of the students but also the conditions that negatively affected the care provided to the patient in the clinic. The clinical practice environment affects the feelings and thoughts of midwifery students about the birth process. For this reason, improving the clinical practice environment and supporting students throughout the education process may contribute to the development of positive feelings and thoughts when attending as a student for their first birth suite placement.

Prevalence and bidirectional association of sleep quality and gut health among Chinese midwives: a large population, multi-center cross-sectional study.

Background: Shift work can disrupt sleep quality and gut health. Nurses and midwives constitute approximately half of the global healthcare shift-working workforce. Our previous study revealed that most midwives were experiencing suboptimal health conditions, characterized by poor sleep quality and a high prevalence of gastrointestinal diseases. The gut-brain axis theory highlights the potential interplay between sleep quality and gut health. However, limited research focuses on this relationship among midwives. Methods: A cross-sectional survey included 2041 midwives from 87 Chinese hospitals between March and October 2023. Participants completed standardized questionnaires assessing sleep quality, gut health, depression, anxiety, and work stress. Binary logistic regression analyzed factors associated with poor sleep, and multiple linear regression examined the influence of sleep quality on gut health. Results: Over 60% of midwives reported poor sleep, with many experiencing gastrointestinal disorders. We observed a bidirectional relationship between sleep quality and gut health among midwives. After multivariable adjustments, midwives with higher gut health scores were more likely to experience poor sleep quality (odds ratio = 1.042, 95% confidence interval = 1.03-1.054). Conversely, midwives with higher sleep quality scores were also more likely to have poor gut health (ß = 0.222, 95% confidence interval = 0.529-0.797). These associations remained robust across sensitivity analyses. Furthermore, depression, anxiety, and work stress significantly affected both sleep quality and gut health among midwives. Conclusion: This study enhances our understanding of the intricate relationship between sleep quality and gut health among midwives. Poor gut health was associated with a higher risk of poor sleep, and vice versa. To improve the overall wellbeing of midwives, the findings emphasize the importance of addressing poor sleep quality and promoting gut health through maintaining a healthy diet, lifestyle, and good mental health. Further studies are needed to confirm our findings and clarify the underlying mechanisms.

Midwife-led psycho-education intervention to reduce childbirth fear: a quasi-experimental study.

This quasi-experimental study aimed to assess the impact of a midwife-led psycho-education intervention on reducing fear of childbirth (FOC) and perceived stress (PS) in pregnant women. The present study involved 96 pregnant women. The intervention group received three 30-45 min telephone sessions using 'BELIEF' (Birth Emotion-Looking to Improve Expectant Fear) psycho-education approach. The outcomes were assessed using questionnaires on childbirth attitudes and PS. Data analysis was performed using Stata version 17. In the intervention group, the mean score for FOC decreased from 39.41 ± 7.02 to 29.91 ± 5.60 (9.5; 24.1%). The mean difference (MD) of 28.22% was statistically significant (adjusted MD: -10.51, 95% CI: -11.60, -9.41, P < 0.001). In the intervention group, mean scores for PS decreased from 22.77 ± 6.94 to 18.23 ± 5.69 (4.54; 19.93%). In the control group, scores increased from 22.68 ± 6.76 to 24.82 ± 6.58 (2.14; 9.43%). The 29.36% MD was statistically significant (aMD: -6.95, 95% CI: -8.73, -5.18, P < 0.001). The findings of this study indicate that the midwife-led psycho-education intervention, utilizing the 'BELIEF' protocol over the telephone, has a significant effect on reducing FOC and PS, as well as increasing the preference for vaginal birth.

Women's expectations, preferences and needs in midwifery care - results from the qualitative Midwifery Care (MiCa) study: Childbirth and early parenthood.

OBJECTIVE: The main goals of our study were (I) the investigation of expectations and preferences as well as (II) the determination of needs of women in regard to midwifery care. DESIGN: Descriptive phenomenology was used to investigate the ways in which women experienced childbirth and early parenthood. A descriptive qualitative research design was chosen, using focus groups. SETTING: ix online focus groups were carried out with 19 women for this part of the Midwifery Care (MiCa) study, mainly from the north of Germany. PARTICIPANTS: Women shortly after birth, in puerperium and the first year after childbirth were recruited in Germany. A purposeful strategy according to maximum variation sampling was applied to reach diversity in the sample regarding age and previous children. Data were analysed using qualitative content analysis, according to Mayring, with support of the qualitative data analysis software MAXQDA 2022. FINDINGS: Six main categories were derived for both childbirth and early parenthood: (a) involvement of family, (b) need for information, (c) physical and psychological aspects and (d) orientation in the healthcare system. In each group, one main category about provision of healthcare was developed: (e) care around childbirth and (f) midwifery care in early parenthood. Women attached great importance to the communication with midwives and favoured the involvement of their partners in the childbirth process and during parenting. Based on different experiences and inconsistency of information, women would prefer consistency in staff and communication as well as standardised information. CONCLUSIONS: From the user's perspective, midwifery care is crucial during childbirth and the child's first year of life. Current health care during and after childbirth and early parenthood lacks individualised care models, emotional support, adequate and professional communication between different health care providers, and consistency in midwifery care. Our findings should be translated into health care delivery with effective interprofessional teamwork within the continuity of midwifery care. Further quantitative research should analyse the individual healthcare situations of women in the reproductive phase of their life as well as of the applied healthcare models in order to personalise care and to improve healthcare quality.

Investigating midwives and nurses reporting of 'infant feeding at hospital discharge': an online survey across NSW Australia.

BACKGROUND: The collection of data on 'infant feeding at hospital discharge' is used to monitor breastfeeding outcomes, health service benchmarking, and research. While some Australian states have clear definitions of this data collection point, there is no operational definition of 'infant feeding at hospital discharge' in the Australian state of New South Wales. Little is known about how midwives interpret the term 'infant feeding at hospital discharge', in particular, the timeframe used to calculate these important indicators. The purpose of this study was to explore midwives' and nurses' practices of reporting 'infant feeding at hospital discharge' in the Australian state of New South Wales. METHODS: An online survey was distributed across public and private maternity hospitals in New South Wales, Australia. The survey asked midwives and nurses their practice of reporting 'infant feeding at discharge' from categories offered by the state Mothers and Babies report of either "full breastfeeding", "any breastfeeding", and "infant formula only". The Qualtrics survey was available from December 2021 to May 2022. RESULTS: There were 319 completed surveys for analysis and all 15 NSW Health Districts were represented. Some participants reported using the timeframe 'since birth' as a reference (39%), however, the majority (54%, n = 173) referenced one of the feeding timeframes within the previous 24 h. Most midwives and nurses (83%, n = 265) recommended 24 h before discharge as the most relevant reference timeframe, and 65% (n = 207) were in favour of recording data on 'exclusive breastfeeding' since birth. CONCLUSION: This study identified multiple practice inconsistencies within New South Wales reporting of 'infant feeding at hospital discharge'. This has ramifications for key health statistics, state reporting, and national benchmarking. While the Baby Friendly Hospital Initiative accreditation requires hospitals to demonstrate and continuously monitor at least a 75% exclusive breastfeeding rate on discharge, only 11 New South Wales facilities have achieved this accreditation. We recommend introducing an option to collect 'exclusive breastfeeding' on discharge' which is in line with participant recommendations and the Baby Friendly Hospital accreditation. Other important considerations are the updated World Health Organization indicators such as, "Ever breastfed"; "Early initiation of breastfeeding" (first hour); "Exclusively breastfed for the first two days after birth".

Utilization of technology to provide on-the-job trainings on Emergency Obstetric and Neonatal Care: Perspectives of nurses and midwives working in Rwanda's remote health facilities.

INTRODUCTION: One of the targets for the third sustainable development goals is to reduce worldwide maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030. To address issues affecting women and the newborns during childbirth and postnatal period, concerted efforts from governments and their stakeholders are crucial to maximize the use of technology to enhance frontline health professionals' skills to provide the emergency obstetric and newborn care (EmONC). However, no study has garnered nurses' and midwives' perspectives regarding the application of technology-enhanced learning approach to provide on-the-job Continuous Professional Development (CPD) and factors that may influence the application of this training approach in the Rwandan context. METHODS: The study collected data from nurses and midwives from forty (40) public health facilities in remote areas nationwide. The study applied a qualitative descriptive design to explore and describe nurses' and midwives' perspectives on the feasibility and acceptability of technology enhanced learning approaches such as e-learning, phone-based remote training, and other online methods to provide trainings in EmONC. Two focus group discussions with EmONC mentors, two with nurses and midwives were conducted. Twelve key informant interviews were conducted. Participants were selected purposively. In total, 54 individuals were included in this study. A thematic approach was used to analyse data. RESULTS: Nurses and midwives highlighted the need to provide refresher trainings about the management of pre-eclampsia. Most of the EmONC trainings are still provided face-to-face and the use of technology enhanced learning approaches have not yet been embraced in delivering EmONC CPDs for nurses and midwives in remote areas. Nurses and midwives found the first developed prototype of smartphone app training of the EmONC acceptable as it met the midwives' expectations in terms of the knowledge and skills' gap in EmONC. CONCLUSION: Although the newly developed application was found acceptable, further research involving practical sessions by nurses and midwives using the developed application is needed to garner views about the ease of use of the application, relevance of the EmONC uploaded content on the app, and needed improvements on the app to address their needs in EmONC.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review.

Background: Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. Aim: To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines. Data sources: First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. Results: We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Conclusions: Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being. Future work: Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. Limitations: The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample. Study registration: This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

The National Health Service needs healthy, motivated staff to provide high-quality patient care. Nurses, midwives and paramedics experience poor psychological health (e.g. stress/anxiety) because of pressured environments and the difficulties of healthcare work. This study planned to better understand the causes of poor psychological ill-health in nurses, midwives and paramedics and find which interventions might help and why. We analysed the literature using a method called 'realist review' to understand how interventions work (or not), why, and for who. We tested our findings with patients, the public, nurses, midwives and paramedics in our stakeholder group. We reviewed over 200 papers/reports and identified five main findings: (1) existing solutions (interventions) are disjointed, focus mainly on the individual (not the system) and do not recognise enduring stressors enough; (2) when there is a blame culture it is difficult to encourage staff psychological well-being; (3) the needs of the system often override staff psychological well-being at work; (4) upholding and implementing personal and professional values at work can have negative personal costs; and (5) it is difficult to design, identify and implement solutions that work well for staff groups in different circumstances with varied causes of poor psychological health. Healthcare organisations should consider: (1) changing (rebalancing) the working environment to help healthcare professionals rest, recover and thrive; (2) investing in multiple-level system (not just individual) approaches to staff psychological well-being; (3) continuing to reduce stigma; (4) ensuring the essential needs of staff are prioritised (rest-breaks/hydration/hot food) as building blocks for other solutions; (5) addressing the blame culture, assuming staff are doing their best in difficult conditions; (6) prioritising staff needs, as well as patient needs. We will provide guidance and recommendations to policy-makers and organisational leaders to improve work cultures that tackle psychological ill-health and suggest new areas for research.

National norms for the obstetric nurses' and midwives' health education competence, and its influencing factors: a nationwide cross-sectional study.

BACKGROUND: Strengthening obstetric nurses' and midwives' health education competence is the investment and guarantee for the population's future health. The purpose of study is to establish national norms for their health education competence, and explore possible influencing factors for providing an uniform criterion identifying levels and weaknesses. METHODS: An online questionnaire with a standard process was used to collect data. Three normative models were constructed, and multiple linear regression analysis analyzed possible influencing factors. RESULTS: The sample respondents (n = 3027) represented obstetric nurses and midwives nationally. Three health education competency normative norms (mean, percentile and demarcation norm) were constructed separately. Locations, hospital grade, department, marital status, training times and satisfaction with health education training influenced obstetrical nurses' and midwives' health education competence (P<0.05). CONCLUSION: This study constructed the first national standard for assessing obstetric nurses' and midwives' health education competence, providing a scientific reference to evaluate the degree of health education competence directly. These known factors could help clinical and policy managers designate practice improvement measures. In future research, Grade I hospitals should be studied with larger sample sizes, and indicators need to improve to reflect health education's effect better.

Midwife continuity of care models versus other models of care for childbearing women.

BACKGROUND: Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016. OBJECTIVES: To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies. SELECTION CRITERIA: All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence. MAIN RESULTS: We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models. AUTHORS' CONCLUSIONS: Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Do we know where we are heading?

Sam Foster, Executive Director of Professional Practice, Nursing and Midwifery Council, considers the issue of long-term workforce planning, focusing on England.

Inpatient midwifery staffing levels and postpartum readmissions: a retrospective multicentre longitudinal study.

BACKGROUND: Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings. METHODS: We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service. RESULTS: 64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant). CONCLUSION: We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

Nepal needs Continuing Professional Development for Re-registration in Nursing and Midwifery.

The nursing and midwifery profession needs to stay up to date with the latest developments.  In this Viewpoint, we shall be referring to 'nurses' and 'nursing' to mean 'nurses and midwives' and 'nursing and midwifery' respectively. Nurses must continue to update their skills and competences to meet changing future population health needs effectively and safely. However, the reality is that many staff are reporting difficulty accessing and completing Continuing Professional Development (CPD) in all settings. Keywords: CPD; midwifery; nursing; post-registration education; training.

Implementing digital sexual and reproductive health care services in youth clinics: a qualitative study on perceived barriers and facilitators among midwives in Stockholm, Sweden.

BACKGROUND: Digital health care services have the potential to improve access to sexual and reproductive health care for youth but require substantial implementation efforts to translate into individual and public health gains. Health care providers are influential both regarding implementation and utilization of the services, and hence, their perceptions of digital health care services and the implementation process are essential to identify and address. The aim of this study was to explore midwives' perception of digital sexual and reproductive health care services for youth, and to identify perceived barriers and facilitators of the implementation of digital health care provision in youth clinics. METHODS: We performed semi-structured interviews with midwives (n = 16) working at youth clinics providing both on-site and digital sexual and reproductive health care services to youth in Stockholm, Sweden. Interview data were analyzed using a content analysis approach guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Midwives acknowledged that the implementation of digital health care improved the overall access and timeliness of the services at youth clinics. The ability to accommodate the needs of youth regarding their preferred meeting environment (digital or on-site) and easy access to follow-up consultations were identified as benefits of digital health care. Challenges to provide digital health care included communication barriers, privacy and confidentiality concerns, time constraints, inability to offer digital appointments for social counselling, and midwives' preference for in person consultations. Experiencing organizational support during the implementation was appreciated but varied between the respondents. CONCLUSION: Digital sexual and reproductive health care services could increase access and are valuable complements to on-site services in youth clinics. Sufficient training for midwives and organizational support are crucial to ensure high quality health care. Privacy and safety concerns for the youth might aggravate implementation of digital health care. Future research could focus on equitable access and youth' perceptions of digital health care services for sexual and reproductive health.