Endorsed midwife prescribing in Australia: "[For] the women, more than anything".

PROBLEM: Prescribing by Endorsed Midwives has existed in Australia for more than ten years. Significant barriers exist in the bureaucracy surrounding prescribing and state and territory legislation which further constrain midwives capacity to prescribe required medications. BACKGROUND: Current evidence indicates Endorsed Midwives improve timely access to medications and can experience both enablers and barriers to prescribing. AIM: To explore Endorsed Midwives' lived experiences of medication prescribing, including which medications are being prescribed, how this affects the women in their care, midwives' practice, and perspectives on the future of midwifery prescribing. METHODS: A descriptive qualitative approach was used. Data collection occurred through semi-structured interviews (n=10) of Endorsed Midwives from varied Australian practice contexts and locations. Data analysis followed Reflexive Thematic Analysis. FINDINGS: Four themes were developed: Medication prescription as essential healthcare; Prescribing optimises midwifery practice; External structures can both promote and inhibit the capacity to prescribe; The future of prescribing. DISCUSSION: Endorsed Midwife prescribing has the potential to positively impact women's maternity care and enable midwives to fulfil their scope of practice. However, limitations to prescribing need to be addressed to capitalise on these benefits. CONCLUSION: Significant reform of health service policy, state and territory legislation and further development of the Pharmaceutical Benefits Scheme are required to fully embrace and capitalise on the full scope of Endorsed Midwives in the Australian Healthcare system.

Impact of disrespectful maternity care on childbirth complications: a multicentre cross-sectional study in Ethiopia.

BACKGROUND: Globally, disrespectful, and abusive childbirth practices negatively impact women's health, create barriers to accessing health facilities, and contribute to poor birth experiences and adverse outcomes for both mothers and newborns. However, the degree to which disrespectful maternity care is associated with complications during childbirth is poorly understood, particularly in Ethiopia. AIM: To determine the extent to which disrespectful maternity care is associated with maternal and neonatal-related complications in central Ethiopia. METHODS: A multicentre cross-sectional study was conducted in the West Shewa Zone of Oromia, Ethiopia. The sample size was determined using the single population proportion formula. Participants (n = 440) were selected with a simple random sampling technique using computer-generated random numbers. Data were collected through face-to-face interviews with a pretested questionnaire and were entered into Epidata and subsequently exported to STATA version 17 for the final analysis. Analyses included descriptive statistics and binary logistic regression, with a 95% confidence interval (CI) and an odds ratio (OR) of 0.05. Co-founders were controlled by adjusting for maternal sociodemographic characteristics. The primary exposure was disrespectful maternity care; the main outcomes were maternal and neonatal-related complications. RESULTS: Disrespectful maternity care was reported by 344 women (78.2%) [95% CI: 74-82]. Complications were recorded in one-third of mothers (33.4%) and neonates (30%). Disrespectful maternity care was significantly associated with maternal (AOR = 2.22, 95% CI: 1.29, 3.8) and neonatal-related complications (AOR = 2.78, 95% CI: 1.54, 5.04). CONCLUSION: The World Health Organization advocates respectful maternal care during facility-based childbirth to improve the quality of care and outcomes. However, the findings of this study indicated high mistreatment and abuse during childbirth in central Ethiopia and a significant association between such mistreatment and the occurrence of both maternal and neonatal complications during childbirth. Therefore, healthcare professionals ought to prioritise respectful maternity care to achieve improved birth outcomes and alleviate mistreatment and abuse within the healthcare sector.

Endorsed midwives prescribing scheduled medicines in Australia: A scoping review.

PROBLEM: Despite 10 years of prescribing scheduled medicines by Endorsed Midwives, little is known about prescribing practices. BACKGROUND: Endorsed Midwives can prescribe scheduled medicines and have access to Medicare rebates to support service provision. Endorsed Midwives have the potential to improve access to medications for women, however, are met with barriers, including inconsistencies in state and national legislation. AIM: To search for what is published regarding Endorsed Midwife prescribing of scheduled medicines in Australia, report on the literature, synthesise the findings and discuss the results. METHODS: A scoping review utilising the Joanna Brigg's Institute methodology. A search of CINAHL, PubMed, Science Direct and Medline databases was conducted. Seven peer-reviewed articles were identified; three discussion papers, one literature review and three research papers, published between 2016 and 2023 in English. Qualitative content analysis was used to identify topic areas. FINDINGS: Four topic areas were identified: 1) Endorsed Midwives increase women's access to prescribed medications; 2) the Pharmaceutical Benefits Scheme is restrictive and diminishes midwifery prescribing; 3) medication prescribing depends on internal and external structures; 4) professional relationships support prescribing. DISCUSSION: The authority to prescribe augments Endorsed Midwives' practice, improves timely access to medications and enhances role satisfaction. The effective use of midwifery prescribing is hampered by barriers such as the Pharmaceutical Benefits Scheme, inappropriate medication formularies, and poorly designed health service policy. CONCLUSION: To fully utilise Endorsed Midwife prescribing in all settings of maternity care, further work is required to develop education, remove barriers, and demonstrate the safety and effectiveness of midwifery prescribing.

An exploratory study of women and midwives' perceptions of environmental waste management - homebirth as climate action.

BACKGROUND: Inspired by observing midwives working with birthing women in Bali and at homebirths in Australia, this study explores the meanings associated with environmental waste at birth. AIMS: The aim is to better understand how and why women and midwives from the homebirth community in Australia choose to manage waste generated during the birthing process. Babies across the globe are born without a carbon footprint and are united, no matter their location, by a future that will require an understanding of and action against climate change. METHODS: This qualitative exploratory study investigated midwives' (n = 10) and women's (n = 10) perspectives on environmental waste generated from birth at home. Data were collected through semi-structured interviews and analysed thematically. RESULTS: Three overarching themes were identified from the data. The first theme "There is minimal waste from birth at home" demonstrates participants' perception of the difference in waste generated by birth at home compared to birth in a hospital. The second theme, "Organic waste from homebirth is beneficial to the environment," spoke to participants' embeddedness and connections within their surrounding community environment. The third theme, "Formal education around managing waste at homebirth doesn't exist," indicates a lack of structured or official education or training programs available to individuals interested in learning about sustainable waste management practices during home birth. CONCLUSION: Birthing at home has a low environmental impact as clinical waste is negligible. This research demonstrates a need to incorporate sustainable waste management into midwifery education while respecting midwifery practices in the home setting.

Translating Cultural Safety to the UK.

Disproportional morbidity and mortality experienced by ethnic minorities in the UK have been highlighted by the COVID-19 pandemic. The 'Black Lives Matter' movement has exposed structural racism's contribution to these health inequities. 'Cultural Safety', an antiracist, decolonising and educational innovation originating in New Zealand, has been adopted in Australia. Cultural Safety aims to dismantle barriers faced by colonised Indigenous peoples in mainstream healthcare by addressing systemic racism.This paper explores what it means to be 'culturally safe'. The ways in which New Zealand and Australia are incorporating Cultural Safety into educating healthcare professionals and in day-to-day practice in medicine are highlighted. We consider the 'nuts and bolts' of translating Cultural Safety into the UK to reduce racism within healthcare. Listening to the voices of black, Asian and minority ethnic National Health Service (NHS) consumers, education in reflexivity, both personal and organisational within the NHS are key. By listening to Indigenous colonised peoples, the ex-Empire may find solutions to health inequity. A decolonising feedback loop is required; however, we should take care not to culturally appropriate this valuable reverse innovation.

"I didn't feel like I could trust her and that felt really risky": a phenomenographic exploration of how Australian Midwives describe intrapartum risk.

OBJECTIVE: Concepts of intrapartum risk are not well explored in the Australian context. In response to an increasing focus on risk in maternity care, we sought to obtain insight into what Australian midwives conceptualised as intrapartum risk. DESIGN: The research was conducted using a phenomenographic approach. Following ethical approval, in-depth semi-structured interviews were used to determine the qualitatively different ways midwives conceptualise intrapartum risk. SETTING: This project was undertaken across different midwifery practice settings in Australia. PARTICIPANTS: Australian midwives (n=14) with expertise in caring for women in the intrapartum period volunteered to participate in the study. FINDINGS: When discussing their experience of intrapartum risk, midwives focused on the external horizon of the woman as the risk, that included the internal horizons of being labelled as clinically high risk, working relationships within transdisciplinary risk and institutional risk. Risks were orientated toward the woman as well as to the midwives. KEY CONCLUSIONS: The midwives in this study conceptualised that intrapartum risk was associated with the woman including being labelled as high risk in addition to certain challenges within the midwife-woman relationship, particularly if there was a lack of reciprocal trust. IMPLICATIONS FOR PRACTICE: This study supports current evidence that improved collaborative professional relationships are integral to safety in maternity care. It reinforces continuity of midwifery care as important, and particularly as a way of mitigating intrapartum risk. Further research is required to inform what challenges experienced in the midwife-woman relationship contribute to concepts of risk.

Influence of grandmothers on breastfeeding practices in a rural community in Papua New Guinea: A critical discourse analysis of first-time mothers' perspectives.

BACKGROUND: Almost all babies are breastfed in Papua New Guinea (PNG); yet appropriate breastfeeding practices are not always followed. AIM: To explore the perspectives of first-time mothers in rural PNG on how the language and discourse of grandmothers about infant feeding influence their breastfeeding practices. METHODS: A critical discourse analysis (CDA) approach was used to theoretically frame the analysis of twenty first-time mothers' narratives. FINDINGS: Analysis revealed three themes: (i) prescribed knowledge repository, (ii) social control and dominance, and (iii) disapproval and role conflict, which provides an understanding of grandmothers' differing views and positions on infant feeding practices and their influence on breastfeeding. CONCLUSION: This study shows that grandmothers remain influential in infant feeding practices in rural PNG. There appears to be a societal expectation that empowers grandmothers in the maternal decision-making processes regarding breastfeeding practice. Grandmothers' influence includes the early introduction of complementary foods to infants less than six months old. Interventions aimed at promoting, protecting, and supporting breastfeeding need to include grandmothers.

Learning to be a midwife: Midwifery students' experiences of an extended placement within a midwifery group practice.

AIM: To investigate the experiences, perspectives and plans of students who had a six-month placement with the midwifery group practice. METHODS: Focus groups were conducted with fifteen third - year Bachelor of Midwifery students who had undertaken an extended placement at a midwifery group practice in a large tertiary referral hospital in Queensland, Australia. RESULTS: Four main themes were identified in the data: Expectations of the Placement; Facilitating learning within a midwifery group practice model; Transitioning between models of care and Philosophy and culture of midwifery group practice. DISCUSSION AND CONCLUSION: Third-year midwifery students valued the experience of working one-on-one for an extended placement with a midwife providing continuity of care within a caseload model. The experience was the highlight of their degree and they learned 'how to be a midwife'. Most students found reintegrating back into the hospital system of care challenging, reporting that their developed skills of supporting women holistically and facilitating normal birth were not fully utilised when returning to the task-orientated birth suite. Students valued thoughtful, kind and supportive midwifery preceptors who supported them to transition back into the hospital. IMPLICATIONS AND RECOMMENDATIONS: Undertaking an extended placement within a midwifery group practice provides students with a rich and holistic learning experience and helps them develop a sense of professional identity. Student placements situated within models of care which provide continuity of midwifery care should be proactively enabled by health services and universities. Research of the longer-term impacts of an extended midwifery group practice clinical placement on midwifery graduates' capabilities and competencies 3-5 years post registration should be conducted.

Early career midwives' perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments.

OBJECTIVE: The aim of this study was to investigate whether a specifically designed whole-ofdegree strategy utilising groupwork assessments was effective in facilitating the development of early career midwives' teamwork skills. DESIGN AND METHODS: A qualitative study using in-depth, semi-structured interviews was undertaken with early career midwives who had graduated within the previous two years. This study is the final cycle of a larger participatory action research project. Qualitative data was analysed using thematic analysis. PARTICIPANTS: Nineteen early career midwives from one Australian university participated. Their preregistration education was via a Bachelor of Midwifery. Their education included a whole-of-degree educational strategy to facilitate the development of teamwork skills. FINDINGS: One overarching theme "Becoming an Effective Team Member' and three sub-themes: 'Learning and developing Teamwork Skills'; 'More secure and confident' and 'Self-Assurance in interprofessional interactions' were identified in the interview data. Despite their junior status, the midwives demonstrated the knowledge, skills, and attitudes of an effective team member. Their social and emotional skills appeared well developed and they felt confident interacting with other health care workers in a professional manner. KEY CONCLUSIONS: Early career midwives who were taught and practiced teamwork skills throughout their degree, appear to have developed the social and emotional competencies required for effective teamwork. IMPLICATIONS FOR PRACTICE: The capacity for effective teamwork of this small group of early career midwives has the potential to improve the quality and safety of their care for childbearing women. Learning teamwork skills in the educational setting appears to have generated skills focused on conflict resolution, emotional self-regulation and social and emotional competency in these new midwives. These are favourable skills in the emotionallycharged environment of maternity care, where inter-collegial bullying is present and where new midwives can experience poor psychological wellbeing. Health care employers want new graduate health professionals to be work ready and to have the skills necessary to be effective team members. The program undertaken by these new graduates may be of assistance in developing these capabilities in other health students. THE KNOWN: Teamwork skills are an intrinsic part of the day-to-day activities of maternity services, influencing the workplace culture, retention of midwives and the quality and safety of care. Poor teamwork is associated with clinical errors, bullying and high turnover of staff. THE NEW: Early career midwives who were taught teamwork skills and practice these skills using their groupwork assignments throughout their undergraduate degree appear to demonstrate the social and emotional competencies required for effective teamwork. THE IMPLICATIONS: Implementing a whole-of-degree program to develop teamwork skills in undergraduate midwifery students may improve early career midwives' social and emotional competencies and interactions with other health professionals. Learning teamwork skills in the educational setting may generate skills in the new midwife that focus on conflict resolution, emotional self-regulation, and social and emotional competency. These are favourable skills in the emotionally charged environment of maternity care, where inter-collegial bullying is present and where new midwives can experience poor psychological wellbeing.

Immediate, uninterrupted skin-to-skin contact and breastfeeding after birth: A cross-sectional electronic survey.

OBJECTIVE: To determine the incidence of immediate, uninterrupted skin-to-skin contact and breastfeeding after birth; and which factors are associated with it. DESIGN: Cross-sectional e-survey was developed and piloted prior to distribution. Sampling was purposive and included snowball sampling. Associations between maternity care practices and the primary outcome measure were examined using logistic regression. SETTING: Australia. PARTICIPANTS: Women who birthed a term baby within the previous three years, in any Australian setting (hospital, birth centre or at home), were eligible to participate. MEASUREMENTS AND FINDINGS: 1200 postpartum women met the eligibility criteria and completed the e-survey. The primary outcome, 'pronurturance', included: (1) immediate mother/baby holding; (2) skin-to-skin contact; (3) uninterrupted holding for at least 60 min; 4) breastfeeding in the birth setting. Of 1200 participants, 22% (n = 258) experienced pronurturance. Pronurturance was less likely following caesarean section (adjusted Odds Ratio (aOR) 0.07, 95% Confidence Interval (CI) 0.03-0.17). Pronurturance was more likely with a known midwife during labour and birth (aOR 1.89, 95% CI 1.35-2.65). Contributing to the low rate of pronurturance were lack of antenatal skin-to-skin information; babies being wrapped; women wearing clothing; and non-urgent caregiver interruptions including weighing the baby or facilitating the mother to shower. KEY CONCLUSION: Health services must strategically address the institutional processes which delay and/or interrupt skin-to-skin contact and breastfeeding in birth suite and operating theatre settings. IMPLICATIONS FOR PRACTICE: Midwives and midwifery students providing continuity of carer are best placed to provide pronurturance to mothers and babies. Caregivers should educate women about pronurturance antenatally, and actively support immediate, uninterrupted mother/baby skin-to-skin contact and breastfeeding after birth.

'TeamUP': An approach to developing teamwork skills in undergraduate midwifery students.

OBJECTIVE: to develop an effective model to enable educators to teach, develop and assess the development of midwifery students' teamwork skills DESIGN: an action research project involving participant interviews and academic feedback. SETTING: a regional university PARTICIPANTS: midwifery students (n = 21) and new graduate midwives (n = 20) INTERVENTIONS: a whole of course program using a rubric, with five teamwork domains and behavioural descriptors, to provide a framework for teaching and assessment. Students self and peer assess. Lectures, tutorials and eight different groupwork assignments of increasing difficulty, spread over the three years of the undergraduate degree are incorporated into the TeamUP model. FINDINGS: the assignments provide students with the opportunity to practice and develop their teamwork skills in a safe, supported environment. KEY CONCLUSIONS: the social, emotional and practical behaviours required for effective teamwork can be taught and developed in undergraduate health students. IMPLICATIONS FOR PRACTICE: students require a clear overview of the TeamUP model at the beginning of the degree. They need to be informed of the skills and behaviours that the TeamUP model is designed to help develop and why they are important. The success of the model depends upon the educator's commitment to supporting students to learn teamwork skills.

Midwifery students experience of teamwork projects involving mark-related peer feedback.

BACKGROUND: Lack of teamwork skills among health care professionals endangers patients and enables workplace bullying. Individual teamwork skills are increasingly being assessed in the undergraduate health courses but rarely defined, made explicit or taught. To remedy these deficiencies we introduced a longitudinal educational strategy across all three years of the Bachelor of Midwifery program. AIM: To report on students' experiences of engaging in team based assignments which involved mark-related peer feedback. METHODS: Stories of midwifery students' experiences were collected from 17 participants across the three years of the degree. These were transcribed and analysed thematically and interpreted using feminist collaborative conversations. RESULTS: Most participants reported being in well-functioning teams and enjoyed the experience; they spoke of 'we' and said 'Everyone was on Board'. Students in poorly functioning teams spoke of 'I' and 'they'. These students complained about the poor performance of others but they didn't speak up because they 'didn't want to make waves' and they didn't have the skills to be able to confidently manage conflict. All participants agreed 'Peer-related marks cause mayhem'. CONCLUSION: Teamwork skills should be specifically taught and assessed. These skills take time to develop. Students, therefore, should be engaged in a teamwork assignment in each semester of the entire program. Peer feedback should be moderated by the teacher and not directly related to marks.

Expert validation of a teamwork assessment rubric: A modified Delphi study.

BACKGROUND: Teamwork is a 'soft skill' employability competence desired by employers. Poor teamwork skills in healthcare have an impact on adverse outcomes. Teamwork skills are rarely the focus of teaching and assessment in undergraduate courses. The TeamUP Rubric is a tool used to teach and evaluate undergraduate students' teamwork skills. Students also use the rubric to give anonymised peer feedback during team-based academic assignments. The rubric's five domains focus on planning, environment, facilitation, conflict management and individual contribution; each domain is grounded in relevant theory. Students earn marks for their teamwork skills; validity of the assessment rubric is critical. QUESTION: To what extent do experts agree that the TeamUP Rubric is a valid assessment of 'teamwork skills'? DESIGN: Modified Delphi technique incorporating Feminist Collaborative Conversations. PARTICIPANTS: A heterogeneous panel of 35 professionals with recognised expertise in communications and/or teamwork. METHODS: Three Delphi rounds using a survey that included the rubric were conducted either face-to-face, by telephone or online. Quantitative analysis yielded item content validity indices (I-CVI); minimum consensus was pre-set at 70%. An average of the I-CVI also yielded sub-scale (domain) (D-CVI/Ave) and scale content validity indices (S-CVI/Ave). After each Delphi round, qualitative data were analysed and interpreted; Feminist Collaborative Conversations by the research team aimed to clarify and confirm consensus about the wording of items on the rubric. RESULTS: Consensus (at 70%) was obtained for all but one behavioural descriptor of the rubric. We modified that descriptor to address expert concerns. The TeamUP Rubric (Version 4) can be considered to be well validated at that level of consensus. The final rubric reflects underpinning theory, with no areas of conceptual overlap between rubric domains. CONCLUSION: The final TeamUP Rubric arising from this study validly measures individual student teamwork skills and can be used with confidence in the university setting.

Effects of skin-to-skin contact and breastfeeding at birth on the incidence of PPH: A physiologically based theory.

BACKGROUND: The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. METHOD: The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. DISCUSSION: The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. CONCLUSION: This biologically based theory hypothesises that to achieve and maintain eutony and eulochia, midwives and birthing women should ensure early, prolonged and undisturbed skin-to-skin contact for mother and baby at birth including easy access for spontaneous breastfeeding.

The development of a rubric for peer assessment of individual teamwork skills in undergraduate midwifery students.

BACKGROUND: Poor teamwork is cited as one of the major root causes of adverse events in healthcare. Bullying, resulting in illness for staff, is an expression of poor teamwork skills. Despite this knowledge, poor teamwork persists in healthcare and teamwork skills are rarely the focus of teaching and assessment in undergraduate health courses. AIM: To develop and implement an assessment tool for use in facilitating midwifery students' learning of teamwork skills. METHODS: This paper describes how the TeamUP rubric tool was developed. A review of the literature found no research reports on how to teach and assess health students' teamwork skills in standing teams. The literature, however, gives guidance about how university educators should evaluate individual students using peer assessment. The developmental processes of the rubric were grounded in the theoretical literature and feminist collaborative conversations. The rubric incorporates five domains of teamwork skills: Fostering a Team Climate; Project Planning; Facilitating Teams; Managing Conflict and Quality Individual Contribution. The process and outcomes of student and academic content validation are described. CONCLUSION: The TeamUP rubric is useful for articulating, teaching and assessing teamwork skills for health professional students. The TeamUP rubric is a robust, theoretically grounded model that defines and details effective teamwork skills and related behaviours. If these skills are mastered, we predict that graduates will be more effective in teams. Our assumption is that graduates, empowered by having these skills, are more likely to manage conflict effectively and less likely to engage in bullying behaviours.

Midwifery students' evaluation of team-based academic assignments involving peer-marking.

BACKGROUND: Midwives should be skilled team workers in maternity units and in group practices. Poor teamwork skills are a significant cause of adverse maternity care outcomes. Despite Australian and International regulatory requirements that all midwifery graduates are competent in teamwork, the systematic teaching and assessment of teamwork skills is lacking in higher education. QUESTION: How do midwifery students evaluate participation in team-based academic assignments, which include giving and receiving peer feedback? PARTICIPANTS: First and third year Bachelor of Midwifery students who volunteered (24 of 56 students). METHODS: Participatory Action Research with data collection via anonymous online surveys. KEY FINDINGS: There was general agreement that team based assignments; (i) should have peer-marking, (ii) help clarify what is meant by teamwork, (iii) develop communication skills, (iv) promote student-to-student learning. Third year students strongly agreed that teams: (i) are valuable preparation for teamwork in practice, (ii) help meet Australian midwifery competency 8, and (iii) were enjoyable. The majority of third year students agreed with statements that their teams were effectively coordinated and team members shared responsibility for work equally; first year students strongly disagreed with these statements. Students' qualitative comments substantiated and expanded on these findings. The majority of students valued teacher feedback on well-developed drafts of the team's assignment prior to marking. CONCLUSION: Based on these findings we changed practice and created more clearly structured team-based assignments with specific marking criteria. We are developing supporting lessons to teach specific teamwork skills: together these resources are called "TeamUP". TeamUP should be implemented in all pre-registration Midwifery courses to foster students' teamwork skills and readiness for practice.

Reflections on the practice of facilitating group-based antenatal education: should a midwife wear a uniform in the hospital setting?

The first author of this paper, a Thai midwife, conducted a feminist action research project aimed at collaboratively developing a model for group-based antenatal education in Thailand. Should a midwife wear a uniform when facilitating midwife-led group-based antenatal education sessions in the hospital setting? This paper reports on a single example of reflection in and on midwifery practice that aimed to answer the guiding question. The practice and reflection occurred over a number of months at the beginning of the feminist action research project. The midwife should wear normal clothes when facilitating group-based antenatal education as a symbol of equality in power relationships within the group. When power relationships between women and the midwife are equalized, women are more able to take responsibility for their health as they are less likely to defer to the 'expert'. Reflection in and on practice is a powerful tool to allow the midwife to understand and change her own practice as required to meet those goals. Self-change is a critical first step because there can be no change in the way maternity care is provided without each midwife being willing to be self-aware and open to appropriate self-change.

The effectiveness of medical interventions aimed at preventing preterm birth: a literature review.

BACKGROUND: Preterm birth is a significant global health problem with serious short and long term consequences. This paper reviews the research literature to answer the question how effective are the medical interventions that aim to reduce the rates of preterm birth? METHODS: A systematic search was carried out in CINAHL, Cochrane, Medline and Embase in relation to following medical treatments aimed at preventing preterm births: anti-infective medications, tocolytics, progesterone and cervical cerclage. The research underpinning each type of intervention is critically analysed in order to establish the validity of knowledge claims that are made for each type of intervention. FINDINGS: In relation to reducing the rates of preterm births, anti-infectives are only effective in the presence of known infection. Screening for infections during pregnancy is ineffective. Tocolytic agents are not effective in decreasing the preterm birth rates. Progesterone seems to be effective in a select group of pregnant women at higher risk of preterm birth. Cervical cerclage plays a small and an occasional role in preventing some preterm births. CONCLUSIONS: This literature review demonstrates that medical interventions aimed at preventing, not just delaying, preterm birth, are not effective at a population level. Providing holistic, antenatal midwifery care for women living in socio-economic disadvantage and/or with an increased risk of preterm birth seems to be a promising strategy to address the negative effects of the social determinants of disease and thus to reduce the rate of preterm births at an individual and a population level.

Inter-professional collaboration in delivery suite: a qualitative study.

BACKGROUND: Communication problems between clinicians are the most common cause of preventable adverse events in hospitals. In spite of these known risks the 'turf wars' between midwives and doctors continue unabated. QUESTION: What factors affect inter-professional interactions in birthing units? PARTICIPANTS: 9 doctors and 10 midwives from 10 Australian maternity units. METHODS: Interpretive Interactionism was the research design. Probing in-depth interviews were conducted to elicit stories of inter-professional interactions and their perceived effects on birthing outcomes. Analysis resulted in two theoretical models of inter-professional interaction: one positive and the other negative. FINDINGS: Midwives and doctors agree that positive interactions are collaborative, include the woman and her partner and are associated with the best possible outcomes and experiences possible. In contrast, they agree that negative interactions involve power struggles between the professionals and these are associated with adverse outcomes. All participants are able to demonstrate emotional and social competence when interacting and applied those skills sometimes. Factors related to the organisational culture within the 'birth territory' of a particular maternity unit seem to be predictive of the type of interactions that are likely to occur there. CONCLUSION: Interventions to enhance inter-professional collaboration should be directed first at changing organisational structures and policies to promote easy opportunities for natural dialogue between doctors and midwives.

Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: a cohort study.

QUESTION: Is 'holistic psychophysiological care' in the third stage of labour safe for women at low risk of postpartum haemorrhage? BACKGROUND: Although there have been four randomised trials and a Cochrane Review on the safety and effectiveness of care during the third stage labour, no previous study has focussed only on women at low risk of postpartum haemorrhage and no previous study has tested a form of physiological third stage care that is provided by skilled midwives in an appropriate setting. DESIGN: Retrospective cohort study involving a maternity unit at a tertiary referral hospital and a freestanding, midwifery-led birthing unit. PARTICIPANTS: All low risk women who gave birth at either unit in the period July 2005-August 2008. INTERVENTIONS: 'Active management' of the third stage of labour compared with 'holistic psychophysiological third stage care'. RESULTS: At the tertiary unit, 344 of 3075 low risk women (11.2%) experienced postpartum haemorrhages (PPH). At the midwifery-led unit, PPH occurred for 10 of 361 women (2.8%), OR=4.4, 95% CI [2.3, 8.4]. Treatment received analysis showed that active management (n=3016) was associated with 347 postpartum haemorrhages (11.5%) compared with receiving holistic psychophysiological care (n=420) which was associated with 7 (1.7%) PPH OR=7.7, 95% CI [3.6, 16.3]. CONCLUSION: This study suggests that 'holistic psychophysiological care' in the third stage labour is safe for women at low risk of postpartum haemorrhage. 'Active management' was associated with a seven to eight fold increase in postpartum haemorrhage rates for this group of women. Further prospective observational evaluation would be helpful in testing this association.