Creative arts intervention in support of women experiencing a high-risk pregnancy: A qualitative descriptive thematic analysis.

BACKGROUND: Mental illness can have negative effects on both the pregnant woman and her unborn child. Studies that use the creative arts as interventions have proven to be beneficial to women's antenatal mental health and wellbeing, however, these studies are limited and emergent. Music, drawing and narrative (MDN) is an established music therapy intervention, stemming from guided imagery and music (GIM), that has the potential to support positive mental health and wellbeing. Yet, to date, there have been limited studies on the use of this form of therapy with inpatient antenatal women. AIM: To describe antenatal inpatient women's experiences of participating in a MDN session. METHODS: Qualitative data were collected from a sample of 12 inpatient pregnant women who participated in MDN group sessions of drawing to music. Post intervention interviews explored the mental and emotional health of participants. A thematic analysis of the transcribed interview data was performed. FINDINGS: Through reflection women were supported to acknowledge both the positives and difficulties of pregnancy as well as establish meaningful connections through shared experience. These thematic findings highlighted that MDN enabled this group of pregnant women to better communicate their feelings, validate emotions, engage in positive distractions, develop greater connections, improve optimism, experience calmness, and learn from others. CONCLUSION: This project demonstrates that MDN may offer a viable method for supporting women experiencing high risk pregnancies.

Parturescence: A theorisation of women's transformation through childbirth.

PROBLEM: The potential for positive transformation through giving birth is under-acknowledged and poorly understood. AIM AND METHOD: By drawing on theories of new feminist materialism to open up ways of thinking about childbirth and maternity care, we discuss how aspects of the process of matrescence, a woman's 'mother-becoming', pertain to women's opportunities in childbirth. We introduce the term, 'parturescence', as a moniker for the opportunity for 'becoming', and therefore transformation, offered in birth giving. RESULTS AND DISCUSSION: Using Davies' interpretation of Bergson's lines of descent and ascent we suggest the conditions of a woman's parturescence (whether birth giving will result in a positive or negative transformation) is enabled by 'with woman' midwifery care. The intra-action between this care, and the materiality of birth - the pain and exhaustion women experience in labour and birth, results in a rematerialisation of who and what women are and the opportunity for women's transformation. CONCLUSION: The development of this theory of parturescence unifies disparate aspects of maternity care and birth literature, provides insight into the potential mechanisms and conditions that impact women's parturescence, and suggests that birth, including the challenging and destabilising parts, is not just for the production of a baby, but also a site of women's 'becoming'.

The relationality of maternity care: A diffractive analysis of maternity care experiences.

PROBLEM: Pervasive polemics of differing approaches to and values of maternity care limit possibilities of nuanced and productive understandings of how maternity care is experienced. AIM: To explore how maternity care identities (midwife, obstetrician, childbearing woman) are shaped by binarised conceptualisations of childbirth. METHODS: The diffractive analysis of data gathered in collective biography research groups. FINDINGS AND DISCUSSION: Maternity care identities are not complete, pre-established entities, but rather are, 'in the making', remade in every maternity care encounter. CONCLUSION: Maternity care identities are defined by their encounters with other maternity care identities, and therefore, each maternity care identity plays a role in which experiences of maternity care come into being.

Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review.

PROBLEM: Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models. BACKGROUND: Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice. AIM: This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women. METHODS: A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis. FINDINGS: Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care. DISCUSSION: Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible. CONCLUSIONS: Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.

Analysing constructions of childbirth in the media; Moving possibilities for childbirth beyond gender essentialism.

PROBLEM: Birth can be a contentious issue with maternity care providers and consumers alike advocating fiercely defended and polarising views. These positions are largely shaped by opposing biomedical and natural childbirth constructions of birth. Contemporary debate on homebirth is one such example which illustrates this divide. AIM: To reconceptualise birth by deconstructing current constructions of childbirth contained in homebirth articles published by one online media source in Australia. METHODS: Australia's self-acclaimed largest women's media company was searched for articles pertaining to homebirth. Articles which met inclusion criteria were analysed using poststructural feminist theory and deconstruction techniques informed by Davies and Gannon, Butler and others. FINDINGS: Gender essentialism present in both the biomedical and natural childbirth approaches constructs birth as an act of nature, dictated by biology rather than one with a sociohistorical location. DISCUSSION: Gender essentialism at birth serves to obscure the sociohistorical determinants of birth, making it appear as a static, immutable sort of act, rather than one which is defined by its sociohistorical location and which can be redefined, even reinvented, by its sociohistorical location. CONCLUSION: Gender essentialism is an enduring phenomenon, underpinning seemingly opposing constructions of childbirth. Disengaging childbirth from essentialisms of woman's nature may create possibilities and meanings of childbirth that could be useful for childbearing women.

The future in their hands: Graduating student midwives' plans, job satisfaction and the desire to work in midwifery continuity of care.

BACKGROUND: Midwife-led continuity of care models benefit women and the midwives who work in them. Australian graduate midwives are familiar with, and educated to provide, continuity of care to women although the opportunity to work exclusively in positions providing continuity of care on graduation is uncommon. AIM: To explore the immediate and aspirational employment plans and workforce choices, reasons for staying in midwifery and perceptions around factors likely to influence job satisfaction of midwives about to graduate from one Australian university during the years 2012-2016. METHODS: This longitudinal study draws on survey responses from five cohorts of midwifery students in their final year of study. FINDINGS: Ninety five out of 137 midwifery students responded to the survey. Almost nine out of ten respondents either aspired to work in a continuity of care model or recognised that they would gain job satisfaction by providing continuity of care to women. Factors leading to job satisfaction identified included making a difference to the women for whom they care, working in models of care which enabled them to provide women with 'the care I want to give', and having the ability to make autonomous midwifery decisions. CONCLUSION: Aligning early graduate work experiences with continuity of care models may have a positive impact on the confidence and professional development of graduate midwives, which in turn may lead to greater satisfaction and retention among a workforce already committed to supporting the maternity healthcare reform agenda.

Outcomes by birth setting and caregiver for low risk women in Indonesia: a systematic literature review.

BACKGROUND: Care for women during pregnancy, labour, birth and the postpartum period is essential to reducing maternal and neonatal mortality and morbidity, however the ideal place and organisation of care provision has not been established. The World Health Organization recommends a two-tier maternity care system involving first-level care in community facilities, with backup obstetric hospital care. However, evidence from high-income countries is increasingly showing benefits for low risk women birthing outside of hospital with skilled birth assistance and access to backup care, including lower rates of intervention. Indonesia is a lower middle-income country with a network of village based midwives who attend births at homes, clinics and hospitals, and has reduced mortality rates in recent decades while maintaining largely low rates of intervention. However, the country has not met its neonatal or maternal mortality reduction goals, and it is unclear whether greater improvements could be made if all women birthed in hospital. BODY: This paper reviewed the literature on birth outcomes by place of birth and/or caregiver for women considering their risk of complications in Indonesia. A systematic literature search of Pubmed, CINAHL, CENTRAL, Web of Science, Popline, WHOLIS and clinical trials registers in 2016 and updated in 2018 resulted in screening 2211 studies after removing duplicates. Twenty four studies were found to present outcomes by place of birth or caregiver and were included. The studies were varied in their findings with respect of the outcomes for women birthing at home and in hospital, with and without skilled care. The quality of most studies was rated as poor or moderate using the Effective Public Health Practice Project Quality Assessment Tool. Only one study gave an overall assessment of the risk status of the women included, making it impossible to draw conclusions about outcomes for low risk women specifically; other studies adjusted for various individual risk factors. CONCLUSION: From the studies in this review, it is impossible to assess the outcomes for low risk women birthing with health professionals within and outside of Indonesian hospitals. This finding is supported by reviews from other countries with developing maternity systems. Better evidence and information is needed before determinations can be made about whether attended birth outside of hospitals is a safe option for low risk women outside of high income countries.

Making the hidden seen: A narrative analysis of the experiences of Assumption of Care at birth.

BACKGROUND: Being involved in any child protection system is complex and multifaceted and none more so than in non-voluntary Assumption of Care which occurs in New South Wales when, for child protection concerns, the Department of Family and Community Services removes a newborn baby from her/his mother. OBJECTIVE: This research studied childbearing women's and professionals' experiences of Assumption of Care at birth to increase understanding of individual participants' stories, how they made sense of meanings and how these experiences framed their lives. METHOD: A narrative inquiry framework guided interviews with four groups: childbearing women, midwives, social workers and Family and Community Services case managers. Holistic form was used for reading, interpreting and analysing the narratives. FINDINGS: This research found unwanted emotional (isolation, shame, guilt, loss, disenfranchised grief) and physical consequences (depression, substance abuse complications) for women experiencing an Assumption of Care at the time of birth. There were also conflicting ethical and moral positions for the professionals involved. The use/abuse of power, concealment of facts and disenfranchised grief were identified as intertwined plots that caused or increased tensions. DISCUSSION: Both the women and the professionals felt pressure from trying to achieve competing and overlapping roles. The unwanted effects of Assumption of Care are exacerbated by the current child protection and maternity care systems. CONCLUSION: To address the tensions raised in this study, we suggest a two-fold change to maternity care for women at risk of an Assumption of Care: a therapeutic justice model of maternity care and continuity of midwifery care with a dedicated midwife. Introducing these changes could increase women's and children's safety and wellbeing.

A researcher's journey: Exploring a sensitive topic with vulnerable women.

BACKGROUND: The conduct of research regardless of the subject or methods employed brings responsibilities and challenges. These are greater when dealing with sensitive topics and vulnerable groups and therefore researchers must navigate a range of complex issues and make choices in relation to practical, ethical and philosophical concerns. While literature dealing with research methodologies and research design may assist to some degree, it cannot provide a clear pathway or template as each research project must respond to a unique set of circumstances. We can however, also learn from sharing our stories and critical reflections on our research processes. OBJECTIVE: The purpose of this article is to highlight the practical and methodological issues arising from researching a sensitive topic with vulnerable women experiencing an Assumption of Care. DISCUSSION: Research involving topics that are deeply personal and private combined with a vulnerable population can be complex and challenging for the researcher. Although some issues were anticipated from the literature, others encountered in this study were unexpected. Special considerations and prerequisites were necessary to build mutual trust and share power with women who had experienced an Assumption of Care at birth. Narrative Inquiry was a good methodological fit for this study as it privileged the voices of women and insisted that their experiences be considered within the context of their lives. CONCLUSION: Although Narrative Inquiry is a suitable choice for researching sensitive topics with vulnerable women specific considerations are still required to ensure the benefits of this research for both participants and researchers. Family and Community Service (FACS) have now replaced the formerly known Department of Community Services (DoCS) and in consideration of the timing of this study this article uses the terminology as DoCS.

Sense of coherence and women׳s birthing outcomes: A longitudinal survey.

BACKGROUND: in Western countries, caesarean section rates are increasing at an alarming rate. This trend has implications for women׳s health and calls into question the use of pathogenesis to frame maternity services. The theory of salutogenesis offers an alternative as it focuses on health rather than illness. Sense of coherence (SOC), the cornerstone of salutogenesis, is a predictive indicator of health. This study aimed to explore associations between pregnant women׳s SOC, their birthing outcomes and factors associated with SOC changes. METHODS: a longitudinal survey was conducted where women completed a questionnaire in the antenatal and postnatal period. Questionnaire one provided information on SOC scores, Edinburgh Postnatal Depression Scale (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices and demographics. Questionnaire two provided information on SOC scores, EPDS scores and birthing outcomes. FINDINGS: 1074 women completed questionnaire one and 753 women completed questionnaire two. Compared to women with low antenatal SOC, women with high antenatal SOC were less likely to experience caesarean section (OR 0.437 95% CI 0.209-0.915) and more likely to experience assisted vaginal birth (AVB) (OR 3.108 95% CI 1.557-6.203). Higher birth satisfaction, higher antenatal EPDS scores and lower antenatal SOC were associated with an increase in SOC. Epidural, AVB and decreased birth satisfaction were associated with a decrease in SOC. CONCLUSION: high sense of coherence in pregnant women is associated with half the likelihood of caesarean section compared to women with low sense of coherence. Women׳s sense of coherence is raised and lowered by degree of satisfaction with their births and lowered by some labour interventions.

Sense of coherence and childbearing choices: A cross sectional survey.

BACKGROUND: as concern for increasing rates of caesarean section and interventions in childbirth in Western countries mounts, the utility of the risk approach (inherent in the biomedical model of maternity care) is called into question. The theory of salutogenesis offers an alternative as it focuses on the causes of health rather than the causes of illness. Sense of coherence (SOC), the cornerstone of salutogenic theory, is a predictive indicator of health. We hypothesised that there is a relationship between a woman's SOC and the childbirth choices she makes in pregnancy. METHODS: the study aims to investigate the relationship between SOC and women's pregnancy and anticipated labour choices. A cross sectional survey was conducted where eligible women completed a questionnaire that provided information on SOC scores, Edinburgh Postnatal Depression (EPDS) scores, Support Behaviour Inventory (SBI) scores, pregnancy choices and demographics. FINDINGS: 1074 pregnant women completed the study. Compared to women with low SOC, women with high SOC were older, were less likely to identify pregnancy conditions, had lower EPDS scores and higher SBI scores. SOC was not associated with women's pregnancy choices. CONCLUSION: this study relates SOC to physical and emotional health in pregnancy as women with high SOC were less likely to identify pregnancy conditions, had less depressive symptoms and perceived higher levels of support compared to women with low SOC. Interestingly, SOC was not associated with pregnancy choices known to increase normal birth rates. More research is required to explore the relationship between SOC and women's birthing outcomes.

Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital.

BACKGROUND: There is national and international concern for increasing obstetric intervention in childbirth and rising caesarean section rates. Repeat caesarean section is a major contributing factor, making primiparous women an important target for strategies to reduce unnecessary intervention and surgeries in childbirth. AIM: The aim was to compare outcomes for a cohort of low risk primiparous women who accessed a midwifery continuity model of care with those who received standard public care in the same tertiary hospital. METHODS: A retrospective comparative cohort study design was implemented drawing on data from two databases held by a tertiary hospital for the period 1 January 2010 to 31 December 2011. Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. RESULTS: Data for 426 women experiencing continuity of midwifery care and 1220 experiencing standard public care were compared. The study found increased rates of normal vaginal birth (57.7% vs. 48.9% p=0.002) and spontaneous vaginal birth (38% vs. 22.4% p=<0.001) and decreased rates of instrumental birth (23.5% vs. 28.5% p=0.050) and caesarean sections (18.8% vs. 22.5% p=0.115) in the midwifery continuity cohort. There were also fewer interventions in this group. No differences were found in neonatal outcomes. CONCLUSION: Strategies for reducing caesarean section rates and interventions in childbirth should focus on primiparous women as a priority. This study demonstrates the effectiveness of continuity midwifery models, suggesting that this is an important strategy for improving outcomes in this population.

Examining the Validity and Reliability of Antonovsky's Sense of Coherence Scale in a Population of Pregnant Australian Women.

Antonovsky's Orientation to Life questionnaires were developed to measure sense of coherence (SOC). Although the SOC 13 instrument is widely used to measure health in general populations, it has not been assessed in pregnant women. If the SOC 13 is to be used to assess women's childbearing health, it requires further examination. The purpose of the research is to assess the psychometric properties of Antonovsky's SOC 13 questionnaire in pregnant women. When administered to 718 pregnant Australian women, the construct validity of the SOC 13 was difficult to establish. The SOC 9 was created by removing 4 items and provided best data fit. The SOC 13 and SOC 9 were found to have sound criterion validity, internal reliability, and equivalence between versions. It is hoped that the present study will stimulate additional research on SOC scales to examine their ability to assess women's childbearing health.

Guilty until proven innocent?--the Assumption of Care of a baby at birth.

BACKGROUND: This paper provides an overview of the history of child protection, the associated law and the 2008 amendments to the Child and Young Persons (Care and Protection) Act 1998 in relation to the Assumption of Care at birth practice. OBJECTIVE: To explore the current practice of an Assumption of Care (AOC) where a newborn baby is removed from his/her mother at the time of birth, particularly focussing on the impact of the AOC on midwives. DISCUSSION: Assumption of Care practices in NSW raise significant issues for midwives in relation to the midwifery codes of ethics and conduct and importantly, to their ability to work in ways that honour a "woman-centred care" philosophy. When midwives are exposed to conflict between workplace and personal or professional values such as the practice of AOC cognitive dissonance can occur. CONCLUSIONS: Further research is required to understand the impact of current Assumption of Care. Broader research to not only look at effect on the midwife but also on other health professionals involved and the women who personally experience the removal of their baby at the time of birth. Consideration must also be given to ways of working with vulnerable families to enhance the acceptability and efficacy of maternity services and with associated agencies will decrease the need for Assumption of Care at birth.

"Continuity of care" experiences in midwifery education: perspectives from diverse stakeholders.

At least 20 continuity-of-care experiences are compulsory for student midwives in Australia, but little is known about this learning component. This paper presents an analysis of continuity experiences in one Region, incorporating diverse stakeholder perspectives from student midwives, maternity managers and registered midwives, with the aim of better understanding and optimizing experiences. Qualitative methods were utilized, employing mainly focus groups. Participants included 15 student midwives from the Regional University, 14 midwives and six managers, employed at the Regional referral hospital. Four themes were identified in the data; "woman-centred care", "counting the cost", "mutual benefits" and "into the future". The significant benefits of student continuity-of-care experiences were outlined by all three participant groups. Continuity experiences for student midwives facilitated the development of a woman-centred focus in the provision of maternity care. While the experience was challenging for students it was beneficial not only to them, but to registered midwives, the maternity services, and ultimately childbearing women. In order to appropriately prepare midwives for existing and future maternity services, and to continue to meet women's needs in all service delivery models, we require midwives who are well grounded in a woman-centred care philosophy and have had exposure to various care models.

Socially disadvantaged women's views of barriers to feeling safe to engage in decision-making in maternity care.

BACKGROUND: Although midwifery literature suggests that woman-centred care can improve the birthing experiences of women and birth outcomes for women and babies, recent research has identified challenges in supporting socially disadvantaged women to engage in decision-making regarding care options in order to attain a sense of control within their maternity care encounters. OBJECTIVE: The objective of this paper is to provide an understanding of the issues that affect the socially disadvantaged woman's ability to actively engage in decision-making processes relevant to her care. RESEARCH DESIGN: The qualitative approach known as Interpretative Phenomenological Analysis was used to gain an understanding of maternity care encounters as experienced by each of the following cohorts: socially disadvantaged women, registered midwives and student midwives. This paper focuses specifically on data from participating socially disadvantaged women that relate to the elements of woman-centred care-choice and control and their understandings of capacity to engage in their maternity care encounters. FINDINGS: Socially disadvantaged women participants did not feel safe to engage in discussions regarding choice or to seek control within their maternity care encounters. Situations such as inadequate contextualised information, perceived risks in not conforming to routine procedures, and the actions and reactions of midwives when these women did seek choice or control resulted in a silent compliance. This response was interpreted as a consequence of women's decisions to accept responsibility for their baby's wellbeing by delegating health care decision-making to the health care professional. CONCLUSION: This research found that socially disadvantaged women want to engage in their care. However without adequate information and facilitation of choice by midwives, they believe they are outsiders to the maternity care culture and decision-making processes. Consequently, they delegate responsibility for maternity care choices to those who do belong; midwives. These findings suggest that midwives need to better communicate a valuing of the woman's participation in decision-making processes and to work with women so they do have a sense of belonging within the maternity care environment. Midwives need to ensure that socially disadvantaged women do feel safe about having a voice regarding their choices and find ways to give them a sense of control within their maternity care encounters.

'It's a good thing ': Women's views on their continuity experiences with midwifery students from one Australian region.

BACKGROUND: midwifery relationships, especially ones developed over time, are viewed and valued as practical and political health interventions that increase the likelihood of good health for women and infants and assist with health challenges. Thus the continuity relationships with women required for each Bachelor of Midwifery student are used, not only to expand students' learning but also, in a fragmented maternity care system, to provide opportunities for women to experience the care of a known person through their pregnancy, labour and early parenting time. AIM OF THE STUDY: we sought understandings of women's experiences of their continuity relationships with midwifery students. METHOD: a survey was posted to all women (n=1008) who had agreed to continuity in the first years of our undergraduate program 2009-2011. We analysed 354 completed surveys (34% response rate). SPSS was used for quantitative data and content analysis identified themes expressed in the qualitative responses from a selected sub-set of 27 participants. Ethical approval was obtained from the authors' institution and research funding from the local registration board. FINDINGS: women's satisfaction of being with a student in a continuity relationship was high. On a scale from one (not at all satisfied) to 10 (extremely satisfied), the mean score was 8.88. The women, more than half of whom received standard maternity care, stated they valued the opportunity for a constant presence across their childbearing experience and will recommend student continuity to their friends. CONCLUSIONS AND IMPLICATIONS: this study shows that our curriculum emphasis on continuity is valued by women. Pairing a woman and a student gives women a relationship with a named person in the maternity health field that provides valued extras: care, time, patience, effort, information, advocacy, support and kindness. It raises the profile of midwifery in the community, especially the profile of continuity of midwifery care for women in standard models of care. It increases communication for and with women in a variety of useful and desirable ways and it allows an opportunity for women to contribute to students' learning. It also provides the university sector a chance to value and privilege the continuity of midwifery relationship.

'You've got it within you': the political act of keeping a wellness focus in the antenatal time.

OBJECTIVE: by exploring midwives' communication techniques intended to promote a wellness focus in the antenatal period, this study identified strategies midwives use to amplify women's own resources and capacities, with the aim of reducing antenatal anxiety. DESIGN: a qualitative design utilising focus groups as a means of generating data. SETTING: two Australian cities: Canberra, ACT and Sydney NSW. PARTICIPANTS: 14 experienced, practising midwives across two states/territories, employed in multiple hospitals and community settings. FINDINGS: three themes emerged from the analysis: calm unhurriedness, speaking in wellness and reassuring bodies. Midwives in these focus groups used strategies in antenatal care that could be co-ordinated into a planned process for wellness focussed care. KEY CONCLUSIONS: individually midwives used a variety of strategies specifically intended to facilitate women's capabilities, to employ worry usefully and to reduce anxiety. Midwives in the study clearly viewed this kind of wellness focussed care as their responsibility and their right. IMPLICATIONS FOR PRACTICE: the midwives' collective wisdom could be shared and developed further into an overall salutogenic antenatal strategy to be used for the good of pregnant women and their infants.

Does antenatal education affect labour and birth? A structured review of the literature.

OBJECTIVE: To undertake a structured review of the literature to determine the effect of antenatal education on labour and birth, particularly normal birth. METHOD: Ovid Medline, CINAHL, Cochrane and Web of Knowledge databases were searched to identify research articles published in English from 2000 to 2012, using specified search terms in a variety of combinations. All articles included in this structured review were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). FINDINGS: The labour and birthing effects on women attending antenatal education may include less false labour admissions, more partner involvement, less anxiety but more labour interventions. CONCLUSION: This literature review has identified that antenatal education may have some positive effects on women's labour and birth including less false labour admissions, less anxiety and more partner involvement. There may also be some negative effects. Several studies found increased labour and birth interventions such as induction of labour and epidural use. There is contradictory evidence on the effect of antenatal education on mode of birth. More research is required to explore the impact of antenatal education on women's birthing outcomes.

Slow midwifery.

Some patterns of timekeeping and counting are fraught in midwifery. In this paper we suggest our societal love affair with all things fast can cause us, as midwives, to limit women's possibilities (and our own). We suggest that timekeeping and counting potentially disrupt the midwife-woman relationship and, further, timekeeping and counting contribute to us valuing particular qualities in women and in the health system, including the idea that fast is better than slow. Pondering how this could be different, we consider a beginning global trend about time and speed--the Slow movement--and suggest a new movement, 'Slow Midwifery', in which midwives bear the responsibility of trying to be more connected to the women with whom we work by being less connected to our watches.