Sexual and reproductive health education: Midwives' confidence and practices.

PROBLEM: There is limited evidence regarding midwives' confidence and practices in providing sexual and reproductive health care in Australia. BACKGROUND: Midwives provide important public health education to women regarding sexual and reproductive health care. AIM: The aim of this study was to explore midwives' confidence and practices around providing education to women on three key areas of sexual and reproductive health: contraception and family planning; sexual activity; and sexual health. METHODS: A cross-sectional exploratory study was conducted with responses from n = 164 midwives (43.1% response rate) working in a public tertiary maternity hospital in Western Australia. The survey included items measuring confidence; method and frequency of practice. Open-ended questions captured qualitative data. Data analysis was conducted using descriptive statistics for quantitative data and content analysis for qualitative data. FINDINGS: There was a significant association between age, years of clinical experience (p = 0.001) and work setting (p = 0.032) on the confidence to provide education on sexual activity. Most (92.1%) midwives indicated that they wanted further education. Lack of time, knowledge and language barriers were key factors preventing education. DISCUSSION: Midwives' provision of education to women is essential for improving health literacy and health outcomes. Results reveal the necessity to include sexual and reproductive health education in entry to registration courses and the importance of continuing professional development. CONCLUSION: Evidence of midwives' confidence and current practices in the provision of sexual and reproductive health care offers utility for leaders and educators in midwifery to prepare and equip midwives to fulfil this important public health role.

Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery.

BACKGROUND: Despite the advancement of scientific research in the field of maternity care, midwives face challenges translating latest evidence into evidence-based practice (EBP) and express reticence towards leading practice change in clinical areas. This study aimed to explore midwifery leaders' views on what factors help or hinder midwives' efforts to translate latest evidence into everyday practice and consider them in relation to both the Capability, Opportunity, Motivation and Behaviour (COM-B) model and Theoretical Domains Framework (TDF). METHODS: This qualitative study formed part of a larger action research (AR) project that was designed to improve midwives' EBP implementation capability. Data were obtained from eight Western Australian midwifery leaders who were employed in either managerial or executive positions within their organisation. Five midwives attended a focus group workshop and three opted for face-to-face interviews. Thematic analysis was used to code the transcribed data and group alike findings into sub-categories, which were collapsed to four major categories and one overarching core finding. These were mapped to a matrix combining the COM-B and TDF to establish the usability of these tools in midwifery contexts. RESULTS: Four major categories were developed from the data collected in this study. Three reported the hindrances midwives' experienced when trying to initiate new EBPs: 'For midwives, medical opposition and workplace culture are the biggest challenges', 'Fear can stop change: it's personal for midwives' and 'Midwives are tired of fighting the battle for EBP; they need knowledge and the confidence to bring about practice change.' The other major category highlighted factors midwives' considered helpers of EBP: 'Having stakeholder buy-in and strong midwifery leadership is a huge advantage.' When mapped to the TDF and COM-B, these findings provided valuable insight into the helpers of and hindrances to evidence-based practice in midwifery. CONCLUSION: Midwives are motivated to initiate evidence-based change yet have limited knowledge of implementation processes or the confidence to lead practice change. Factors such as inter-disciplinary buy-in, clear instruction for midwives and support from midwifery leaders were considered beneficial to implementing practice change in clinical areas. The TDF when used in combination with the COM-B was deemed useful to midwives wanting to lead practice change projects in clinical areas.

Midwifery leaders' views on the factors considered crucial to implementing evidence-based practice in clinical areas.

PROBLEM: The evidence-to-practice gap continues to persist in healthcare and midwives report limited knowledge and use of effective intervention strategies to support the implementation of new evidence-based practices in clinical settings. BACKGROUND: Despite ongoing development and dissemination of high quality research findings, the translation of latest research evidence by midwives into new evidence-based practices remains sub-optimal. This inefficiency places consumers at risk of obsolete or potentially dangerous healthcare interventions. AIM: To explore midwifery leaders' views on what information and support midwives require to lead practice change initiatives in clinical areas. METHODS: The study formed part of a broader Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical settings. The study employed a qualitative design and was guided by the methodological underpinnings of Action Research (AR). FINDINGS: One core finding emerged to fulfil the aim and objectives of the study. To lead implementation of evidence-based practices, midwives need practical solutions and a map of the process, packaged into a centralised web-based resource. DISCUSSION: The findings reported in this study provide valuable insight into the specific needs of midwives wanting to improve the uptake and longevity of new evidence based practices in clinical areas. This includes information specific to evidence implementation, support networks and knowledge of Implementation Science. CONCLUSION: To lead practice change initiatives, midwives require a web-based resource that standardises the process of evidence implementation, while providing midwives with clear direction and the support needed to confidently champion for evidence base change in clinical areas.

Midwives' use of best available evidence in practice: An integrative review.

AIMS AND OBJECTIVES: To synthesise international research that relates to midwives' use of best available evidence in practice settings and identify key issues relating to the translation of latest evidence into everyday maternity care. BACKGROUND: Midwifery is a research-informed profession. However, a gap persists in the translation of best available evidence into practice settings, compromising gold standard maternity care and delaying the translation of new knowledge into everyday practice. DESIGN: A five-step integrative review approach, based on a series of articles published by the Joanna Briggs Institute (JBI) for conducting systematic reviews, was used to facilitate development of a search strategy, selection criteria and quality appraisal process, and the extraction and synthesis of data to inform an integrative review. METHODS: The databases CINAHL, MEDLINE, Web of Science, Implementation Science Journal and Scopus were searched for relevant articles. The screening and quality appraisal process complied with the PRISMA 2009 checklist. Narrative analysis was used to develop sub-categories and dimensions from the data, which were then synthesised to form two major categories that together answer the review question. RESULTS: The six articles reviewed report on midwives' use of best available evidence in Australia, the UK and Asia. Two major categories emerged that confirm that although midwifery values evidence-based practice (EBP), evidence-informed maternity care is not always employed in clinical settings. Additionally, closure of the evidence-to-practice gap in maternity care requires a multidimensional approach. CONCLUSION: Collaborative partnerships between midwives and researchers are necessary to initiate strategies that support midwives' efforts to facilitate the timely movement of best available evidence into practice. RELEVANCE TO CLINICAL PRACTICE: Understanding midwives' use of best available evidence in practice will direct future efforts towards the development of mechanisms that facilitate the timely uptake of latest evidence by all maternity care providers working in clinical settings.

Midwives' experience of their education, knowledge and practice around immersion in water for labour or birth.

BACKGROUND: There is limited research examining midwives' education, knowledge and practice around immersion in water for labour or birth. Our aim was to address this gap in evidence and build knowledge around this important topic. METHODS: This mixed method study was performed in two phases, between August and December 2016, in the birth centre of a tertiary public maternity hospital in Western Australia. Phase one utilised a cross sectional design to examine perceptions of education, knowledge and practice around immersion in water for labour or birth through a questionnaire. Phase two employed a qualitative descriptive design and focus groups to explore what midwives enjoyed about caring for women who labour or birth in water and the challenges midwives experienced with waterbirth. Frequency distributions were employed for quantitative data. Thematic analysis was undertaken to extract common themes from focus group transcripts. RESULTS: The majority (85%; 29 of 34) of midwives surveyed returned a questionnaire. Results from phase one confirmed that following training, 93% (27 of 29) of midwives felt equipped to facilitate waterbirth and the mean waterbirths required to facilitate confidence was seven. Midwives were confident caring for women in water during the first, second and third stage of labour and enjoyed facilitating water immersion for labour and birth. Finally, responses to labour and birth scenarios indicated midwives were practicing according to state-wide clinical guidance. Phase two included two focus groups of seven and five midwives. Exploration of what midwives enjoyed about caring for women who used water immersion revealed three themes: instinctive birthing; woman-centred atmosphere; and undisturbed space. Exploration of the challenges experienced with waterbirth revealed two themes: learning through reflection and facilities required to support waterbirth. CONCLUSIONS: This research contributes to the growing knowledge base examining midwives' education, knowledge and practice around immersion in water for labour or birth. It also highlights the importance of exploring what immersion in water for labour and birth offers midwives, as this research suggests they are integral to sustaining waterbirth as an option for low risk women.

Midwives' knowledge, attitudes and learning needs regarding antenatal vaccination.

OBJECTIVE: To determine the knowledge, attitudes and learning needs of midwives regarding antenatal vaccination. DESIGN AND SETTING: A cross-sectional, paper-based survey of midwives employed at the only public tertiary maternity hospital in the Australian state of Western Australia between November 2015 and July 2016. PARTICIPANTS: 252 midwives providing care in antepartum, intrapartum, and/or postpartum settings. MEASUREMENTS: Self-reported responses to a 41-item survey. FINDINGS: The vast majority of midwives supported influenza and pertussis vaccination for pregnant women, with 90.0% and 71.7% reporting they would recommend pertussis and influenza vaccine, respectively, to a pregnant friend or family member, and almost all stating that midwives should administer vaccines to pregnant patients (94.8%). Seven out of ten midwives (68.1%) responded correctly to all knowledge items regarding vaccines recommended during pregnancy; 52.8% demonstrated correct knowledge regarding vaccine administration despite only 36.6% having attended an education session on antenatal vaccination in the previous two years. Nearly all midwives (97.3%) expressed a need for more education on vaccine administration. The most commonly reported barrier to administering influenza (61.3%) and pertussis (59.0%) vaccination was having staff available with the certification required to administer vaccines. KEY CONCLUSIONS: Midwives view antenatal vaccination as their responsibility and are interested and receptive to education. IMPLICATIONS FOR PRACTICE: There is an unmet need and demand among midwives for professional development that would enable them to recommend and administer vaccines to pregnant women in accordance with national immunisation guidelines and integrate vaccination into routine antenatal care.

Obstetric and neonatal outcomes for women intending to use immersion in water for labour and birth in Western Australia (2015-2016): A retrospective audit of clinical outcomes.

BACKGROUND: Research supports water immersion for labour if women are healthy, with no obstetric or medical risk factors. AIMS: To evaluate the obstetric and neonatal outcomes of women intending to use immersion in water for labour or birth. METHODS: Retrospective audit of clinical outcomes for women intending to labour or birth in water conducted between July 2015 and June 2016, at a tertiary maternity hospital in Western Australia. Obstetric and neonatal data were collected from medical records. Multivariable logistic regression was utilised to investigate women who laboured in water stratified by those who birthed in water. RESULTS: A total of 502 women intended to labour or birth in water; 199 (40%) did not and 303 (60%) did. The majority of women using water immersion (179 of 303; 59%) birthed in water. Multiparous women were more likely than primparous to birth in water (73% vs 46%; P < 0.001). Women who birthed in water were at increased odds of: a first stage labour ≤240 min (odds ratio (OR) 2.56, 95% CI 1.34-4.87, P = 0.004); a second stage ≤60 min (OR 3.53, 95% CI 1.82-6.84, P < 0.000); a third stage labour of 11-30 min (OR 2.15, 95% CI 1.23-3.78, P = 0.008); and having an intact perineum (OR 3.10, 95% CI 1.70-5.64, P < 0.000). CONCLUSION: Not all women who set out to labour and birth in water achieve their aim. There is a need for high-quality collaborative research into this option of labour and birth, so women can make an informed choice around this birth option.

Maternity high-dependency care and the Australian midwife: A review of the literature.

BACKGROUND: Maternity high-dependency care has emerged throughout the 21st century in Australian maternity hospitals as a distinct sub-speciality of maternity care. However, what the care involves, how and why it should be provided, and the role of midwives in the provision of such care remains highly variable. INTRODUCTION: Rising levels of maternal morbidity from non-obstetric causes have led midwives to work with women who require highly complex care, beyond the standard customary midwifery role. Whilst the nursing profession has developed and refined its expertise as a specialty in the field of high-dependency care, the midwifery profession has been less likely to pursue this as a specific area of practice. DISCUSSION: This paper explores the literature surrounding maternity high-dependency care. From the articles reviewed, four key themes emerge which include; the need for maternity high-dependency care, maternal morbidity and maternity high-dependency care, the role of the midwife and maternity high-dependency care and midwifery education and preparation for practice. It highlights the challenges that health services are faced with in order to provide maternity high-dependency care to women. Some of these challenges include resourcing and budgeting limitations, availability of educators with the expertise to train staff, and the availability of suitably trained staff to care for the women when required. CONCLUSION: In order to provide maternity high-dependency care, midwives need to be suitably equipped with the knowledge and skills required to do so.

'Teaching on the Run' with Australian midwives in a tertiary maternity hospital.

Teaching On The Run (TOTR) is an Australian program for health professionals involved in clinical supervision. An amended TOTR program was evaluated with midwives acting as preceptors assisting learners integrate theory with clinical practice. A mixed method study was employed to compare midwives' perceived skills and confidence before and after completion of TOTR workshops. A secondary aim explored midwifery learners' (students and new graduates) perceptions of support from preceptors during the implementation of TOTR. Sixty five midwives completed the TOTR workshops with 46 providing data before program enrolment and 1-3 months after completion of the final TOTR workshop. Significant improvements were found for midwifery preceptors with before and after comparisons using Preceptor Self-Efficacy and Self-Evaluation Questionnaires. Using the Nursing Facilitator Clinical Questionnaire, preceptees or midwifery learners (n = 49) scored the 'qualities of their preceptors', 'their clinical practice', 'clinical learning' and 'how feedback was provided' highly with no changes between 2013 and 2014. Nineteen students then participated in three focus group interviews, analyzed using a six step systematic process. One overarching theme, 'Guiding me through' emerged with four themes: 'Getting to know each other'; 'Willingness to share knowledge'; 'Leading by example'; and 'The system acknowledging and valuing the preceptor role'.

Tanzanian midwives' perception of their professional role and implications for continuing professional development education.

This study explored Tanzanian midwives' perceptions of their professional role within their local context. Findings were to inform recommendations for continuing professional development education programs by Western midwifery educators. Using focus group interviews with sixteen Tanzanian midwives, the findings revealed that the midwives' overwhelming focus was on saving lives of women and newborns. The fundamental elements of saving lives involved prioritising care through receiving handover and undertaking physical assessment. Midwives were challenged by the poor working conditions, perceived lack of knowledge and associated low status within the local community. Based upon these findings, recommendations for continuing professional development education for Tanzanian midwives must ensure that saving lives is a major focus and that strategies taught must be relevant to the low-resource context of this developing country. In recognition of the high-risk women being cared for, there needs to be a focus on the prevention and management of maternity emergencies, in collaboration with medical practitioners.

Exploring midwives' perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study.

OBJECTIVE: the option of labouring and/or birthing immersed in warm water has become widely available throughout hospitals in the United Kingdom and Europe over the last two decades. The practice, which also occurs in New Zealand and interstate in Australia, has until recently only been available in Western Australia for women birthing at home with a small publically funded Community Midwifery Program. Despite its popularity and acceptance elsewhere, birth in water has only recently become an option for women attending some public health services in Western Australia. The Clinical Guidelines developed for the local context that support water birth require that the midwives be confident and competent to care for these women. The issue of competency can be addressed with relative ease by maternity care providers; however confidence is rather more difficult to teach, foster and attain. Clinical confidence is an integral element of clinical judgement and promotes patient safety and comfort. For this reason confident midwives are an essential requirement to support the option of water birth in Western Australia. The aim of this study was to capture midwives' perceptions of becoming and being confident in conducting water birth in addition to factors perceived to inhibit and facilitate the development of that confidence. DESIGN: a modified grounded theory methodology with thematic analysis. SETTINGS: four public maternity services offering the option of water birth in the Perth metropolitan area. PARTICIPANTS: registered midwives employed at one of the four publicly funded maternity services that offered the option of water birth between June 2011 and June 2013. Sixteen midwives were interviewed on a one to one basis. An additional 10 midwives participated in a focus group interview. FINDINGS: three main categories emerged from the data analysis: what came before the journey, becoming confident - the journey and staying confident. Each contained between three and five subcategories. Together they depicted how midwives describe the journey to becoming confident to support women who have chosen the option to water birth and how they are able to retain that confidence once achieved. IMPLICATIONS FOR PRACTICE: three key implications emerged from this study, the first was that students and graduate midwives could benefit from the opportunity to work in midwifery led maternity settings that support normal physiological child birth and that accessing such practical placements should be encouraged. Secondly, maternity services would benefit from learning opportunities directed specifically at experienced midwives addressing their particular requirements. Finally, midwives are the custodians of normal physiological birth, attendance at educational days with a focus on supporting this primary role should be mandatory, to inform midwives on current evidence found to support normal birth which includes options such as water birth.

Graduate midwives' perception of their preparation and support in using evidence to advocate for women's choice: A Western Australian study.

A retrospective cohort study was conducted with 83 midwives working across the Western Australian (WA) maternity sector who graduated from one WA University. We explored midwives' attitudes and utilisation of research and assertive communication in addition to perceptions of their educational preparation to advocate for women. The greatest opportunity for research exposure was working on a clinical audit (25.3%). No differences were found between graduate groups using the Edmonton Research Orientation subscales, although findings suggest a positive view towards research. Midwives were more likely to be assertive with their clinical colleagues than a midwifery manager or medical colleague when: expressing their opinions (P = <0.001); saying no (P = <0.001); allowing others to express their opinions (P = <0.001); and making suggestions to others (P = 0.025). A qualitative phase with 15 midwives explored concepts around advocating for women. Four themes emerged: 'having the confidence to question', 'communication skills', work environment' and 'knowing the woman and what she wants'. Findings suggest strategies are needed in their entry to practice preparation and ongoing professional development to facilitate research engagement. Using assertive behaviour to provide feedback to clinical colleagues warrants attention to enhance reflective practice. Building communication skills through observing positive role models and participating in role play was highlighted.

Australian midwives knowledge, attitude and perceived learning needs around perinatal mental health.

DESIGN AND AIM: a cross sectional survey was undertaken to explore midwives' knowledge of, and attitudes towards, mental health disorders in childbearing women vis-à-vis their perceived mental health learning needs. SETTING AND PARTICIPANTS: a 50.1% response rate included 238 midwives employed in the only public tertiary maternity hospital in Western Australia from March to June 2013. METHOD AND FINDINGS: The survey comprised a mixture of custom-designed questions and vignettes presenting various disorders. Only 37.6% of midwives felt well-equipped to support women, whilst 50.2% reported insufficient access to information. Demand was highest for education on: personality disorders (77.8%); the impact of childbearing on mental health disorders (74.2%); and skills for handling stress and aggression (57.8%). Knowledge scores were variable: on average eight out of a maximum 13 questions were answered correctly, but few (2.7%) answered more than 11 correctly, and 3.7% scored ≤4 correct. Across disorders, recognition from vignettes was highest for depression (93.9%), and lowest for schizophrenia (65.6%). Surprisingly, there were no associations between general knowledge scores and previous mental health experience, recent professional development, or access to information around mental health. The majority endorsed positive beliefs about midwives' role in mental health assessment, and belief in women's recovery (83.5%), however, cluster analysis of warmth and competence ratings revealed negative stereotyping of mental health disorders. KEY CONCLUSIONS: Midwives accept it is their role to assess the mental health status of women but many feel ill-equipped to do so and express a strong desire for further knowledge and skills across a range of perinatal mental health topics. Attitudes to recovery are positive but negative stereotypes exist; therefore awareness of potential bias is important to negate their influence on care. IMPLICATIONS FOR PRACTICE: Learning needs may change due to trends in clinical practice. Strategies are needed to recognise negative beliefs and to ensure education is responsive to local contexts.

The association between women's perceptions of professional support and problems experienced on breastfeeding cessation: a Western Australian study.

A cross-sectional survey was used to determine the association among women's breastfeeding problems, their perceptions of support from midwives and child health nurses, and breastfeeding cessation in the first 10 weeks postbirth in a sample of Western Australian women (N = 2669). Primiparous women (75.8%) experienced significantly more problems that multiparous women (52.6%). Although 78.8% of all women agreed or strongly agreed that staff were helpful with feeding, 53.4% confirmed that different midwives offered different feeding advice; however, receiving different advice from midwives around feeding was not associated with breastfeeding cessation. Differences in breastfeeding cessation were associated with parity. Primiparous women's cessation was associated with experiencing any breastfeeding problems, unhelpful hospital midwives, and unhelpful information from child health nurses, whereas for multiparous women, this included 2 or more breastfeeding problems, not being able to choose when to feed, and unhelpful information from child health nurses.

A Western Australian survey of breastfeeding initiation, prevalence and early cessation patterns.

This paper reports on current initiation and prevalence rates, in Western Australia, differentiating 'any' breastfeeding with 'exclusive' breastfeeding whilst exploring patterns and reasons for stopping breastfeeding. The results presented are part of a larger study examining women's perceptions of care and wellbeing in the early postnatal period. A cross sectional survey was used to examine infant feeding practices during the hospital stay and at 9 weeks post birth from Western Australian women with a registered live birth between February and June 2006. Data obtained from 2,669 women revealed a 93% (n = 2,472) initiation rate of any breastfeeding. More multiparous women (73.5%) were exclusively breastfeeding in hospital compared to primiparous women (65.2%), which decreased to 57.1 and 49.2%, respectively at 9 weeks. Of those who had ceased by 9 weeks, more multiparous women (71.1%) ceased before 3 weeks. Reasons cited for ceasing in order of frequency were insufficient milk supply, infant related reasons, pain and discomfort and emotional reasons. Younger maternal age, primiparous women, lower maternal education levels, offering a combination of breast milk and formula in hospital and caesarean birth were significant independent predictors of early cessation. Although initiation rates including "any" breast milk are meeting NHMRC dietary guidelines of 90%, the 60% target of exclusive breastfeeding is not being achieved for 3 months or in fact at 9 weeks. Targeted support for at risk groups such as younger, less well-educated, primiparous women must continue. Evidence based policies to protect breastfeeding must address the practice of offering formula to breastfed infants in hospital and the impact of increasing interventions such as caesarean births.

Western Australian women's perceptions of the style and quality of midwifery postnatal care in hospital and at home.

AIM AND BACKGROUND: An important part of maternity service provision is the care provided by midwives in the immediate postpartum period. Evidence suggests that postpartum morbidity and its impact on women's health after childbirth is an area of genuine concern. In Western Australia there is limited information on women's postpartum health needs and/or the quality of midwifery care provided in hospital and at home. This paper describes Western Australian (WA) women's perceptions of midwifery care in the early postpartum period. METHOD: A cross-sectional, self report survey was used to describe the practical, emotional and informational support provided by midwives in the initial postpartum period. A questionnaire, specially designed for this population, was posted at 8 weeks postpartum to every woman with a registered live birth in WA between February and June 2006. Completed questionnaires were received from 2699 women. Data were analysed using descriptive statistics, t-tests and chi-squared. RESULTS: Results indicate that overall, women were happy with most aspects of midwifery care related to practical advice and assistance in relation to baby care and their immediate physical recovery. Areas that received a less positive rating were related to providing consistent advice, availability of the midwife, emotional care and information on maternal health needs, immunisation and contraception. In general, first time mothers rated both the style and quality of care more negatively than multiparous women. There was a trend by women accessing private hospital care to rank their care less favourably. There were minimal differences noted between women in metropolitan and non-metropolitan areas. Midwifery care at home was rated very positively and significantly better than hospital care (p

A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice.

OBJECTIVES: to describe Australian midwives' experiences of an external review of obstetric services, involvement in legal proceedings and the impact on midwives' clinical practice and personal wellbeing. BACKGROUND: the external review process (commonly referred to as the 'Douglas Inquiry') was initiated by a state government and was in response to hospital staff and consumer complaints that focused on anomalies in client care and a significantly high rate of adverse outcomes and clinical errors. It took place within the context of a number of legal proceedings against medical practitioners. As a result, some midwives employed by the hospital were called to give evidence at a variety of legal forums. DESIGN: a qualitative study using an explorative descriptive design. Snowball sampling was used to invite 16 Australian midwives to participate in a tape-recorded interview. Thematic analysis and the techniques associated with constant comparison were used to analyse the data. SETTING: Australian maternity tertiary referral centre. FINDINGS: the analysis identified two overarching themes, 'A story of scrutiny' and 'A story of fear', each with a number of subthemes. 'A story of scrutiny' consists of three subthemes. 'A cloak and dagger affair' reflects the midwives' sense of being and feeling 'exposed' and 'vulnerable' whilst simultaneously being 'kept in the dark' and uninformed during the review process. The subtheme 'Being thrown to the wolves' describes the midwives' experiences of being involved, as witnesses, in medico-legal proceedings. The third subtheme, 'The Inquiry followed them home' outlines the effect on midwives' emotional wellbeing and personal relationships. The second major theme, 'A story of fear' again consists of a number of subthemes. 'Feeling unsafe at work: a culture of fear' describes the midwives' experiences of working within an environment they perceive as driven by the fear of litigation. In order to protect themselves and maintain a sense of control, the midwives adopted a number of strategies to 'feel safe' including defensive decision making and moving towards a medical philosophy of care. These concepts are captured within the subtheme 'Covering your back: setting boundaries'. The impact on relationships between midwives, women and medical practitioners is described within the subtheme 'Professional relationship: coloured by fear'. The effect on midwives' confidence and the resultant negative emotions elicited make up the subtheme 'Between a rock and a hard place: the midwives' distressing dilemma'. Finally the subtheme, 'Opting out: the changing nature of professional work practices' describes the specific professional decisions and work strategies that midwives made about their ability to continue working in an environment that they perceived as threatening. CONCLUSION: the findings suggest that the midwife participants in this small study were totally unprepared and ill equipped, both personally and professionally, to deal with the consequences of working within an environment that was the centre of a number of high profile legal proceedings and an extensive external review of obstetric services. The midwives were naïve about legal processes and unprepared for the legal 'game playing' and media attention that often accompanies court proceedings. Despite the fact that no midwife faced litigation, the participants described their work environment as becoming increasingly stressful and permeated by a culture of fear. In turn, this situation has reinforced the need for some midwives to adopt an 'institution' ideology which reinforces birth as an abnormal event that needs to be medically managed. This has led to changes in professional and personal work practices. The findings also have implications for the midwifery workforce and retention. Although the findings are context specific, this study provides valuable insight into the phenomena of fear of litigation and its impact on midwifery practice. Given the similarities concerning obstetric litigation in some other Western nations, the findings have relevance in the international midwifery arena.

Providing perinatal loss care: satisfying and dissatisfying aspects for midwives.

PURPOSE: There is limited midwifery research that focuses on midwives experiences and attitudes to providing care for women who experience the death of a baby. There is also limited research investigating care components, and evidence to inform the basis of clinical practice in Australia and internationally. This paper presents the qualitative findings of a small study that aimed to investigate midwives experience, confidence and satisfaction with providing care for women who experienced perinatal loss. PROCEDURE: Eighty-three Western Australian midwives responded to an open ended question asking them to describe the most and least satisfying aspects of their role when providing care to women who experienced a perinatal loss. Thematic analysis was used to analyse the data. FINDINGS: The analysis revealed that Australian midwives gained most satisfaction from providing skilled midwifery care that they considered made a difference to women. This was enabled when midwives were afforded the opportunity to provide continuity of midwifery carer to women throughout the labour, birth and early postnatal period. In terms of the least satisfying aspects of care, midwives identified that they struggled with the emotional commitment needed to provide perinatal loss care, as well as with how to communicate openly and share information with women. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Within the context of the study setting, midwifery care for women following perinatal loss reflects the care components espoused in the literature. There are, however, organisational issues within health care that require commitment to continuity of care and further education of practitioners to enhance outcomes for clients.

The influence of childbirth expectations on Western Australian women's perceptions of their birth experience.

OBJECTIVES: to explore and describe the influence of childbirth expectations on women's perception of their birthing experience and expectations for subsequent births. This was the second phase of a study, the purpose of which its purpose was to determine the childbirth expectations of a cohort of Western Australian women and ascertain factors that influenced these expectations. DESIGN: a qualitative study which used an exploratory descriptive design. Data were collected from in-depth individual interviews. SETTING: Perth, Western Australia. PARTICIPANTS: 20 women, 11 primiparae and nine multiparae, who between them had experienced 31 births. These women had participated in phase one when they were either pregnant or had birthed within the preceding 12 months. Phase two interviews occurred 5-6 months after phase one. FINDINGS: the themes and sub-themes revealed in phase one of the study were supported in phase two. Although women held multiple expectations for birth, specific expectations were regarded as priority. Consequently, to perceive birth as positive, a woman had to achieve her priority expectations. Multiparae reported more positive birth experiences, having altered expectations as a result of previous experiences. Unaffirming birth experiences due to unmet expectations were more common after a first birth. Women with unfulfilled expectations subsequently adapted their expectations to be more achievable thus avoiding disappointment. Supportive behaviours of maternity health-care providers assisted women to evaluate their birth experience as positive even when expectations could not be achieved. IMPLICATIONS FOR PRACTICE: the evaluation of birth experiences as positive or negative is contingent upon achieving most, or at least the priority, childbirth expectation. Knowing a woman's expectations assists the midwife in her advocacy role. This role in assisting women to achieve their expectations is reinforced by this research. Caregivers become even more important when expectations are not able to be realised. Behaviours that encourage involvement and participation in decision-making during birth promote feelings of control, coping and feeling supported, which ultimately are needed for women to assess their birth experience as positive. Achievable expectations, such as 'being flexible' and 'only having a healthy baby' could be regarded as a lessening of ideals. The issue of whether these changing expectations are contributing to the increasing technocratic approach to birth and the resulting devaluing of the normal birth experience requires further debate.

The caregiving experience: how much do health professionals understand?

Legal, social and economic factors have changed the delivery of care to people who have a mental disorder. Many of these people are now treated in the community and they live with or in close proximity to their family. The aim of this paper is to provide health professionals with an insight into the experience of being a caregiver to a person with a person with a mental disorder. For these families caregiving becomes an integral part of everyday life. Positive outcomes for both the caregiver and the ill family member are more likely to occur when effective levels of collaboration exist between health professionals and caregivers. Collaboration is enhanced when caregivers and health professionals value each other's contribution to the ill family member's care. Often the burden, stress, and socio-economic effects on the family caring for a person with mental illness is not sufficiently appreciated and further increases this burden. A review of the literature from the caregiver's perception is presented. An increased understanding of the caregiving experience will enable health professionals to develop and implement strategies that facilitate positive outcomes for the caregiver and the ill family member.