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.

The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography.

BACKGROUND: International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors. AIM: To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making. METHODS: We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was. FINDINGS: CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour. DISCUSSION AND CONCLUSION: Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

"I'm not doing what I should be doing as a midwife": An ethnographic exploration of central fetal monitoring and perceptions of clinical safety.

BACKGROUND: Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common. AIM: This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system. METHODS: An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours. FINDINGS: The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system. DISCUSSION: The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety. CONCLUSION: This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice.

BACKGROUND: The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring. AIM: To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring. METHODS: Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed. FINDINGS: Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible. DISCUSSION AND CONCLUSION: Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.

"My whole room went into chaos because of that thing in the corner": Unintended consequences of a central fetal monitoring system.

OBJECTIVE: Technologies for fetal heart rate monitoring have been widely introduced despite evidence of no improvement in perinatal outcomes. A significant body of research has raised concerns that healthcare information technologies can have unintended consequences. We sought to describe an unintended consequence of central fetal monitoring technology. DESIGN: The research was conducted as an Institutional Ethnography. Data generated from interviews, focus groups, and observations were analysed to generate an account of midwives' experiences with the central fetal monitoring system. SETTING: The birthing unit of one Australian maternity service with a central fetal monitoring system. INFORMANTS: 34 midwives and midwifery students who worked with the central fetal monitoring system. FINDINGS: Midwives described a disruptive social event they named being K2ed. Clinicians responded to perceived cardiotocograph abnormalities by entering the birth room despite the midwife not having requested assistance. Being K2ed disrupted midwives' clinical work and generated anxiety. Clinical communication was undermined, and midwives altered their clinical practice. Midwives performed additional documentation work to attempt to avoid being K2ed. KEY CONCLUSIONS: This is the first report of an unintended consequence relating to central fetal monitoring, demonstrating how central fetal monitoring technology potentially undermines safety by impacting on clinical and relational processes and outcomes in maternity care. IMPLICATIONS FOR PRACTICE: Current evidence does not support implementation or ongoing use of central fetal monitoring systems. Further research is needed to inform scaling down central fetal monitoring systems in a safe and supported way.

"Overwhelmed and out of my depth": Responses from early career midwives in the United Kingdom to the Work, Health and Emotional Lives of Midwives study.

BACKGROUND: Efforts to resolve the longstanding and growing staffing crisis in midwifery in the United Kingdom have been hampered by very poor retention rates, with early career midwives the most likely to report burnout and intention to leave the profession. AIMS: To establish the key, self-described factors of satisfaction and dissatisfaction at work for early career midwives in the United Kingdom, and suggest appropriate and effective retention strategies. METHODS: Thematic analysis was undertaken on a subset of free text responses from midwives who had been qualified for five years or less, collected as part of the United Kingdom arm of the Work, Health and Emotional Lives of Midwives project. FINDINGS: Midwives described feeling immense pressure caused by an unremittingly heavy workload and poor staffing. Where relationships with colleagues were strong, they were described as a protective factor against stress; conversely, negative working relationships compounded pressures. Despite the challenges, many of the midwives reported taking great pleasure in their work, describing it as a source of pride and self-esteem. Midwives valued being treated as individuals and having some control over their shift pattern and area of work. DISCUSSION: These results, which reveal the strain on early career midwives, are consistent with the findings of other large studies on midwives' wellbeing. All available levers should be used to retain and motivate existing staff, and recruit new staff; in the meantime, considerable creativity and effort should be exercised to improve working conditions. CONCLUSION: This analysis provides a 'roadmap' for improving staff wellbeing and potentially retention.

Describing and evaluating a foundational education/training program preparing nurses, midwives and other helping professionals as supervisors of clinical supervision using the Role Development Model.

Clinical supervision is a strategy supporting nurses, midwives and other healthcare professionals in the provision of quality healthcare. Clinical supervision involves regular, protected time for reflection. Adequately prepared supervisors are essential, however there is limited knowledge about education/training programs and even less about those that are not discipline-specific. This paper 1) describes an eight-day foundational program, Clinical Supervision for Role Development Training as situated within the Spurr Supervisor Training Model and, 2) presents the results from routinely collected evaluation data. Simple descriptive analysis and latent content analysis were used to analyse data from 226 participants who filled out a self-administered questionnaire. Participants reported increased knowledge (87.5%), skills (87%) and confidence to apply the techniques learnt (85.5%); 95% found practice sessions to be useful, and expectations of the training had been met. Qualitative data supported the positive quantitative results. The program was positively assessed by participants, irrespective of professional discipline. The pragmatic nature of the training and the safe learning environment was considered important to the development of skills and confidence as a supervisor. A more robust evaluation process and prospective, longitudinal research is needed to better understand the expectations and learning experience of participants, and implementation in the healthcare environment.

Mothers' experiences of pain during breastfeeding in the early postnatal period: A short report in a Swedish context.

OBJECTIVES: The objective was to investigate the prevalence of mothers who experienced pain during breastfeeding in the early postnatal period and to describe associated factors. METHODS: Medical records of 987 mothers and their babies were scrutinized. Chi-square Test, McNemar's test, and relative risk with a 95% confidence interval were applied for analysis. RESULTS: During the in-hospital postnatal stay, 19.5% mothers experienced pain during breastfeeding. At discharge, the rate was 8.8% (ρ < .001) and at the follow-up hospital visit 2 to 3 days after birth 17.5% (ρ = .104). Pain when breastfeeding was associated with primiparity (RR 2.02; 95% CI 1.53-2.66), epidural block during labor (RR 1.50; 95% CI 1.17-1.94), cracked nipples (RR 5.94; 95% CI 4.84-7.27), the use of a nipple shield (RR 6.34; 95% CI 5.43-7.41), supplementary feeding (RR 2.19; 95% CI 1.71-2.80), and longer hospital stay (RR 1.88; 95% CI 1.46-2.42). CONCLUSIONS: During the early postnatal period, Swedish mothers commonly experienced pain during breastfeeding. Although the rate dropped at discharge, it rose again by the time mothers returned for their follow-up visit. The rebound rate could be explained by breast engorgement, a baby's shallow latch or the effect of an epidural block. Midwives and nurses assisting women during intrapartum and postpartum care must be aware of factors associated with pain during early breastfeeding.

Midwifery Student Evaluation of Practice: The MidSTEP tool - Perceptions of clinical learning experiences.

BACKGROUND: Little emphasis has been given to the standardised measurement of midwifery students' perceptions of their clinical learning experiences. AIM: To develop a tool that evaluates students' perceptions of their clinical learning experiences according to environment and impact of preceptors on professional development. METHODS: A cross-sectional design was used. Tool development had three phases: item generation; expert review to assess clarity, apparent internal consistency and content validity; and psychometric testing. All Bachelor of Midwifery students at one university in Australia were invited to complete the online survey. Psychometric testing included dimensionality, internal consistency and test-retest reliability. RESULTS: A 74% (n=279) response rate was achieved. Factor analysis revealed the Clinical Learning Environment Scale and Impact of the Midwifery Preceptor Scale accounting for 53.6% and 71.5% of variance respectively. Both scales were reliable (Cronbach's alpha=.92 and .94) and valid. Overall, students positively rated the clinical learning environment and preceptors' abilities to foster their sense of identity as a midwife. Students were less satisfied with preceptors' understanding of the academic program. DISCUSSION: The new tool consists of two scales that reliably measure midwifery students' perceptions of how the clinical learning environment develops their skills and reflects a midwifery philosophy. Preceptors had a positive influence on students' skills and professional development. CONCLUSIONS: The Midwifery Student Evaluation of Practice tool is the first valid and reliable measure of students' perceptions of their clinical learning experiences. Students' feedback provides valuable information to educators and preceptors on how best to optimise clinical learning.

Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review.

PROBLEM: Caesarean section rates have risen in high-income countries. One of the potential drivers for this is the widespread use of CTG monitoring. BACKGROUND: Intrapartum cardiotocograph monitoring is considered to be indicated for women at risk for poor perinatal outcome. AIM: This systematic literature review with meta-analysis examined randomised controlled trials and non-experimental research to determine whether cardiotocograph monitoring rather than intermittent auscultation during labour was associated with changes in perinatal mortality or cerebral palsy rates for high-risk women. METHODS: A systematic search for research published up to 2019 was conducted using PubMed, CINAHL, Cochrane, and Web of Science databases. Non-experimental and randomised controlled trial research in populations of women at risk which compared intrapartum cardiotocography with intermittent auscultation and reported on stillbirth, neonatal mortality, perinatal mortality and/or cerebral palsy were included. Relative risks were calculated from extracted data, and meta-analysis of randomised controlled trials was undertaken. FINDINGS: Nine randomised controlled trials and 26 non-experimental studies were included. Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates. The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy. DISCUSSION: Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome. CONCLUSION: There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits.

Nurturing autonomy in student midwives within a student led antenatal clinic.

BACKGROUND: A clinical environment that provides meaningful and productive learning experiences is essential for students of all health care professions. To support the learning needs of undergraduate midwifery students and facilitate the continuity of care experiences a student led clinic was established in one South East Queensland maternity unit. AIM: This study explored the experiences and learning processes of previous and current midwifery students undertaking clinical practice within a student led clinic. METHOD: Qualitative descriptive. Ten students that elected to work in the midwifery student led clinic were invited to participate in a one off digitally recorded face to face or telephone interview. Thematic analysis was used to analyse the data set. University ethical approval was granted (NRS/17/15/HREC). FINDINGS: Findings suggest the student led clinic positioned students in the 'driver's seat'. Overwhelmingly students described the clinic as providing them with an array of opportunities to 'lead' care rather than being forced to 'sit and watch'. Students believed the experience of working in the clinic increased their midwifery knowledge, skills, confidence, critical thinking, and the ability to advocate for and empower women. CONCLUSION: High quality and supportive clinical teaching and learning experiences are vital for ensuring the student midwife develops into a competent practitioner who is fit for registration. The evidence from this small study highlights the benefits afforded to students of working in partnership not only with pregnant women but also with their university midwifery lecturer. The student's continuity of care learning experiences appeared to foster and cultivate their capability, identity, purpose, resourcefulness and connection; all the five senses of success.

Measuring physical and mental health during pregnancy and postpartum in an Australian childbearing population - validation of the PROMIS Global Short Form.

BACKGROUND: Health related quality of life is a critical concept during the perinatal period but remains under-researched. The International Consortium for Health Outcomes Measurement have included the Patient Reported Outcomes Measurement Information System (PROMIS®) Global Short Form (GSF) in their core outcome set for pregnancy and childbirth to measure health related quality of life. The PROMIS GSF has not been fully evaluated as a valid and reliable instrument in this population. This study assessed the psychometric properties of the PROMIS GSF during pregnancy and postpartum period. METHODS: PROMIS GSF was administered to a sample of 309 pregnant women at four time-points during pregnancy (≤ 27 and 36-weeks) and postpartum (6- and 26-weeks). The structural validity, internal consistency reliability, construct validity, and responsiveness of the PROMIS GSF were evaluated. The internal structure of the PROMIS GSF was explored using Rasch Measurement Theory. Response format, item fit, differential item functioning (item bias), dimensionality of the scale and its targeting were assessed. RESULTS: Two revised subscales (Mental Health: four items; and Physical Health: five items) showed good fit to the Rasch model. The revised mental health subscale demonstrated good internal consistency reliability during pregnancy and postpartum period (α = .88 and .87, respectively). The internal consistency reliability of the physical health subscale was adequate (α = .76 and .75, respectively). The revised mental health subscale was sensitive to group differences according to a history of mental health disorder, income, smoking status, drug use, stress levels and planned versus unplanned pregnancy. Differences in scores on the revised physical subscale were detected for groups based on obesity, income, drug use, smoking status, stress, and history of mental health disorders. Scores on both subscales recorded significant changes across the four time-points, spanning pregnancy and postpartum period. CONCLUSIONS: The revised version of the PROMIS GSF was better able to measure mental and physical health during pregnancy and postpartum period compared to the original version. Findings support the clinical and research application of the PROMIS GSF within the International Consortium for Health Outcomes Measurement Standard Set of Outcome Measures for Pregnancy and Childbirth. Ongoing psychometric analysis of the PROMIS GSF is recommended in other maternity populations.

Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors.

OBJECTIVE: The overall study aim was to explore the relationship between the emotional wellbeing of UK midwives and their work environment. Specific research questions were to: assess levels of burnout, depression, anxiety and stress experienced by UK midwives; compare levels of burnout, depression, anxiety and stress identified in this sample of UK midwives, with levels reported in Australia, New Zealand and Sweden; identify demographic and work-related factors associated with elevated levels of burnout, depression, anxiety and stress. DESIGN: Cross sectional research design using an online survey. The WHELM survey tool was developed within the Australian maternity context and includes a number of validated measures: The Copenhagen Burnout Inventory (CBI), Depression, Anxiety and Stress Scale (DASS-21), as well as items from the Royal College of Midwives (RCM) 'Why Midwives Leave' study (Ball et al., 2002). SETTING: United Kingdom. PARTICIPANTS: An on-line survey was distributed via the RCM to all full midwife members in 2017 (n = 31,898). DATA ANALYSIS: The demographic and work-related characteristics of the sample were analysed using descriptive analyses. Levels of depression, anxiety, stress and burnout, measured by the CBI and DASS scores, were analysed using non-parametric statistical tests. Comparisons were made between groups based on demographic and work characteristics. Mann-Whitney U tests were used for two group comparisons, and Kruskal Wallis tests were used for groups with 2+ groups. Given the large number of analyses undertaken, statistically significant comparisons were identified with a conservative alpha level (p < .01). FINDINGS: A total of 1997 midwives responded to the survey, representing 16% of the RCM membership. The key results indicate that the UK's midwifery workforce is experiencing significant levels of emotional distress. 83% (n = 1464) of participants scored moderate and above for personal burnout and 67% (n = 1167) recorded moderate and above for work-related burnout. Client-related burnout was low at 15.5% (n = 268). Over one third of participants scored in the moderate/severe/extreme range for stress (36.7%), anxiety (38%) and depression (33%). Personal and work-related burnout scores, and stress, anxiety and depression scores were well above results from other countries in which the WHELM study has been conducted to date. Midwives were more likely to record high levels of burnout, depression, anxiety and stress if they were aged 40 and below; reported having a disability; had less than 10 years' experience; worked in a clinical midwifery setting, particularly if they worked in rotation in hospital and in integrated hospital/community settings. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Many UK midwives are experiencing high levels of stress, burnout, anxiety and depression, which should be of serious concern to the profession and its leaders. NHS employed clinical midwives are at much greater risk of emotional distress than others surveyed, which has serious implications for the delivery of high quality, safe maternity care. It is also of serious concern that younger, more recently qualified midwives recorded some of the highest burnout, stress, anxiety and depression scores, as did midwives who self-reported a disability. There is considerable scope for change across the service. Proactive support needs to be offered to younger, recently qualified midwives and midwives with a disability to help sustain their emotional wellbeing. The profession needs to lobby for systems level changes in how UK maternity care is resourced and provided. Making this happen will require support and commitment from a range of relevant stakeholders, at regional and national levels.

Perinatal incontinence: Psychometric evaluation of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and Wexner Scale.

AIM: The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the Wexner Scale have been included in the International Consortium for Health Outcomes Measurement core outcome set during pregnancy and childbirth, to measure urinary and anal incontinence. The reliability and validity of these instruments have not been fully evaluated in maternity populations. The aim of this study was to conduct a psychometric evaluation of the ICIQ-UI SF and Wexner Scale. METHODS: Consecutive pregnant women (n = 309) who booked for care at one Australian birth facility between August 2017 and April 2018 completed the online surveys. Women who screened positive for urinary and/or anal incontinence were administered the ICIQ-UI SF and/or Wexner Scale during pregnancy ( <27 and 36-weeks) and postpartum (6 and 26-weeks). Scale internal consistency, construct validity, and responsiveness were evaluated. FINDINGS: In women with urinary incontinence, the ICIQ-UI SF demonstrated good internal consistency during pregnancy (baseline and 36 weeks) and 6-weeks postpartum (mean inter-item correlation: 0.47, 0.39, and 0.46, respectively), recorded significant change across three time-points, and was sensitive to group differences in age and obesity during pregnancy. Wexner Scale was unsuitable for psychometric analysis due to insufficient numbers of women with anal incontinence. CONCLUSION: The ICIQ-UI SF is a valid and reliable instrument to measure urinary incontinence during pregnancy and postpartum. The findings support the inclusion of the ICIQ-UI SF in the International Consortium for Health Outcomes Measurement core outcome set for use during the perinatal period. Psychometric analysis of the Wexner Scale in larger maternity populations is recommended.

Cost of maternity care to public hospitals: a first 1000-days perspective from Queensland.

Objective This study sought to compare costs for women giving birth in different public hospital services across Queensland and their babies. Methods A whole-of-population linked administrative dataset was used containing all health service use in a public hospital in Queensland for women who gave birth between 1 July 2012 and 30 June 2015 and their babies. Generalised linear models were used to compare costs over the first 1000 days between hospital and health services. Results The mean unadjusted cost for each woman and her baby (n = 134910) was A$17406 in the first 1000 days. After adjusting for clinical and demographic factors and birth type, women and their babies who birthed in the Cairns Hospital and Health Service (HHS) had costs 19% lower than those who birthed in Gold Coast HHS (95% confidence interval (CI) -32%, -4%); women and their babies who birthed at the Mater public hospitals had costs 28% higher than those who birthed at Gold Coast HHS (95% CI 8, 51). Conclusions There was considerable variation in costs between hospital and health services in Queensland for the costs of delivering maternity care. Cost needs to be considered as an important additional element of monitoring programs. What is known about the topic? The Australian maternal care system delivers high-quality, safe care to Australian mothers. However, this comes at a considerable financial cost to the Australian public health system. It is known that there are variations in the cost of care depending upon the model of care a woman receives, and the type of delivery she has, with higher-cost treatment not necessarily being safer or producing better outcomes. What does this paper add? This paper compares the cost of delivering a full cycle of maternity care to a woman at different HHSs across Queensland. It demonstrates that there is considerable variation in cost across HHSs, even after adjusting for clinical and demographic factors. What are the implications for practitioners? Reporting of cost should be an ongoing part of performance monitoring in public hospital maternity care alongside clinical outcomes to ensure the sustainability of the high-quality maternal health care Australian public hospitals deliver.

Midwifery students' experiences of working within a midwifery caseload model.

BACKGROUND: Work integrated learning opportunities account for approximately half of the Bachelor of Midwifery program with the goal being to ensure that on graduation students are skilled to provide woman centred evidenced based midwifery care within any environment. There is increasing concern, however, over the quality of clinical experiences students are afforded. OBJECTIVE: This study explored the experiences of third year Bachelor of Midwifery students in South East Queensland undertaking a clinical placement within a midwifery caseload model. DESIGN: A qualitative descriptive approach was adopted. Data were collected using semi-structured, digitally recorded telephone interviews. Thematic analysis was used to analyse the data set. SETTING: Midwifery student clinical placement in caseload practice PARTICIPANTS: Twelve third year Bachelor of Midwifery students from one university who had experienced a clinical placement in a caseload midwifery model of between 4 and 8 weeks. FINDINGS: Five themes emerged. These were labelled 'stepping in her shoes', 'bringing it all together', 'my own captive educator', 'knowing the woman', and 'it was hard - but it was worth it'. The three-way relationship between midwife, woman and student facilitated deep and active learning leading to a growth in confidence and readiness for practice. Students were afforded the opportunity to constantly integrate theory into practice within a woman centred social model of care where they also grew to understand how midwives operationalise caseload practice in a sustainable way. Students acknowledged the challenges they faced undertaking the placement, but all confirmed the value it had afforded them. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study has provided evidence that situating midwifery students within a continuity of care model facilitated a rich holistic learning experience for students. Not only did the placement enhance student's confidence and competence it also provided a real-world view of what working in that a caseload model could be like on graduation. This is vital if the profession is to support system level change ensuring all women have access to evidence informed maternity care.

Australian midwives' intentions to leave the profession and the reasons why.

BACKGROUND: There is growing body of evidence that suggests many midwives are unhappy and as a result are making decisions to leave the profession. AIM: Determine the incidence of midwives indicating their intention to leave the profession and explore the reasons for this decision including what might cause midwives to be dissatisfied. METHOD: Data analysed was collected as part of the Australian arm of the Work, Health and Emotional Life of Midwives (WHELM) project. Descriptive statistics and latent content analysis was used to analysis the data set. RESULTS: Almost half (42.8%, n=443/1037) the midwives had considered leaving the profession in the preceding six months. The qualitative and quantitative data aligned with 'dissatisfaction with the organisation of midwifery care' and/or 'dissatisfaction with my role as a midwife' being the two commonest reasons behind the intention to leave. Early career midwives were most likely to consider leaving the profession (p=.05) due to dissatisfaction with their role. Almost half the midwives who had considered leaving the profession were most dissatisfied with managers (p=<.001). CONCLUSION: Midwives felt their ability to provide quality maternity care was constrained by a fragmented medicalised system that did not work for the women in their care or themselves. The results of this study add to a growing call for policy makers and health care providers to reorientate maternity services to enable women to build positive longitudinal relationships with midwives. Not only will this improve maternal and neonatal outcomes but provide a satisfying and sustainable way for working for midwives.

Maori and Pasifika perceptions of their local maternity care in Logan, Australia.

BACKGROUND: Many childbearing women from Maori and Pasifika backgrounds living in the Logan region of Queensland, Australia experience poor health outcomes. Compared to the general population of childbearing women, Maori and Pasifika women are more likely to experience gestational diabetes mellitus and obesity, are less likely to attend recommended antenatal visits and present for initial antenatal visits at later gestations. AIM: To describe women's awareness of maternity service options, explore the barriers to participating in pregnancy care and identify possible enablers to improved uptake of services. METHOD: Qualitative descriptive. Thirty-three women attended one of six culturally specific focus groups. Latent content analysis was used to analyse the data set. FINDINGS: The key source of information for childbearing women was their families. Poor communication, lack of cultural safety and financial constraints were the major barriers to accessing services. Conversely, enablers were perceived to be continuity of midwifery care that was delivered in the community and was culturally safe. DISCUSSION: Strategies to increase uptake of maternity services and optimise services to better meet the needs of women from Maori and Pasifika backgrounds are needed. These should be partnership-based, engage women and families, incorporate cultural needs and preferences and provide services at accessible community locations. CONCLUSION: These findings may be relevant to other groups of women, such as women from culturally diverse backgrounds and from communities experiencing poorer health outcomes.

Socioeconomic differences in access to care in Australia for women fearful of birth.

Objective Fear of childbirth is known to increase a woman's likelihood of having a Caesarean section. Continuity of midwifery care is known to reduce this risk, but less than 8% of women have access to this relationship-based, primary care model. The aims of this study were to determine whether healthcare use and access to continuity models are equal across different indicators of socioeconomic status for women who are fearful of birth. Methods A secondary analysis was conducted of data obtained during a randomised controlled trial of a psychoeducation intervention by trained midwives to minimise childbirth fear (the Birth Emotions and Looking to Improve Expectant Fear (BELIEF) study). In all, 1410 women were screened, with 339 women reporting high levels of fear (Wijma-Delivery Expectancy/Experience Questionnaire ≥66). Demographic, obstetric information, birth preference and psychosocial measures were collected at recruitment and at 36 weeks gestation for the 339 fearful women, with the birth method and health service use returned by 183 women at 6 weeks after the birth. Results Univariate analysis revealed no significant difference in the number of general practitioner and midwife visits between women of high and low income and high and low education. However, women with higher levels of education had 2.51-fold greater odds of seeing the same midwife throughout their pregnancy than women with lower education (95% confidence interval 1.25-5.04), after adjusting for age, parity and hospital site. Conclusions Given the known positive outcomes of continuity of midwifery care for women fearful of birth, health policy makers need to provide equity in access to evidence-based models of midwifery care. What is known about this topic? Caseload midwifery care is considered the gold standard care due to the known positive outcomes it has for the mother and baby during the perinatal period. Pregnant women who receive caseload midwifery care are more likely to experience a normal vaginal birth. What does this paper add? There is unequal access to midwifery caseload care for women fearful of birth across socioeconomic boundaries. Midwifery caseload care is not used for all fearful mothers during the perinatal period. What are the implications for practitioners? Health policy makers seeking to provide equity in access to maternity care should be aware of these inequalities in use to target delivery of care at this specific cohort of mothers.