An evaluation of the quality, suitability and impact on equity of clinical practice guidelines relevant to preterm birth for use in Aotearoa New Zealand.

BACKGROUND: Preterm birth is a leading cause of perinatal morbidity and mortality and a defining event for pregnant people, infants, and whanau (extended families). Recommendations have been made for a national preterm birth prevention initiative focusing on equity in Aotearoa New Zealand, including the development of a national best practice guide. An understanding of the number and quality of guidelines, and consideration of their suitability and impact on equity is required. METHODS: Guidelines were identified through a systematic literature search, search of professional bodies websites, and invitation to regional health services in Aotearoa New Zealand. Obstetric and midwifery clinical directors were invited to report on guideline use. Identified guidelines were appraised by a 23-member trans-disciplinary Review Panel; quantitatively using the AGREE-II instrument and qualitatively using modified ADAPTE questions. The quality of guidelines available but not in use was compared against those in current use, and by health services by level of maternity and neonatal care. Major themes affecting implementation and impact on equity were identified using Braun and Clarke methodology. RESULTS: A total of 235 guidelines were included for appraisal. Guidelines available but not in use by regional health services scored higher in quality than guidelines in current use (median domain score Rigour and Development 47.5 versus 18.8, p < 0.001, median domain score Overall Assessment 62.5 versus 44.4, p < 0.001). Guidelines in use by regional health services with tertiary maternity and neonatal services had higher median AGREE II scores in several domains, than those with secondary level services (median domain score Overall Assessment 50.0 versus 37.5, p < 0.001). Groups identified by the Review Panel as experiencing the greatest constraints and limitations to guideline implementation were rural, provincial, low socioeconomic, Maori, and Pacific populations. Identified themes to improve equity included a targeted approach to groups experiencing the least advantage; a culturally considered approach; nationally consistent guidance; and improved funding to support implementation of guideline recommendations. CONCLUSIONS: We have systematically identified and assessed guidelines on preterm birth. High-quality guidelines will inform a national best practice guide for use in Taonga Tuku Iho, a knowledge translation project for equity in preterm birth care and outcomes in Aotearoa.

Validation of the Chinese version of the Fear of Birth Scale among pregnant women.

AIM: Adapt Fear of Birth Scale (FOBS) for the Chinese context, evaluate psychometric properties and determine optimal cutoff point for pregnant women in 3rd trimester. DESIGN: This is a descriptive cross-sectional study. Cultural guidelines informed the development of the Chinese version of FOBS (FOBS-C) incorporating validation on translation, equivalence index, content validity index, and cognitive debriefing. Thirty pregnant women took a test-retest survey and another 1019 took three cross-sectional surveys. Convergent validation of the FOBS-C involved comparison with Childbirth Attitudes Questionnaire (CAQ), Wijma Delivery Expectancy Questionnaire (WDEQ-A), Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder Scale (GAD-7), and physiological indicators. Cutoff points for FOBS-C were identified using receiver operating characteristic analysis against medical indicators. FINDINGS: FOBS-C demonstrated high translation equivalence (0.833-1), content validity (0.800-0.933), internal consistency (0.897), and test-retest reliability (0.860). Convergent validity was supported by statistically significant correlations between FOBS scores, heart rate, skin conductance changes, as well as scores from WDEQ-A, CAQ, EPDS, and GAD-7. Known-group validity was observed with different medical indicators. FOBS-C cutoff points indicating severe fear of childbirth were identified as 65, 68, 71, and 56, respectively, against WDEQ-A ≥ 85, CAQ ≥ 52, preference for C-section birth, and preference for analgesia, demonstrating known-group validity. A cutoff point of 65 showed the FOBS-C's strongest known-group validity. CONCLUSION: The FOBS-C exhibits robust psychometric properties, making it a valid screening tool for identifying severe fear of birth. Establishing a cutoff point at 65 facilitates effective screening.

Attuning to the World of Peace of Mind and Trust: Women's Lived Experience of the Woman-Midwife Relationship in Japan.

In Japan, many pregnant women and mothers suffer from anxiety, depression, and other postnatal issues that can be exacerbated by their birth experiences. While benefiting from advanced medical care, these women's mental and psychological health may be disregarded in their maternity care. Midwives have the potential to play a significant role in improving women's birth experiences. Hence, this study aimed to explore the meaning of the woman-midwife relationship, with a specific focus on sensing peace of mind and trust to improve women's birth experiences. Using a hermeneutic phenomenological approach, 14 Japanese women were interviewed. Sensing peace of mind and trust was one of the significant meanings of the woman-midwife relationship and is articulated across five themes: (1) attuning to the world, (2) different kinds of safety and trust, (3) relying on and entrusting midwives, (4) making a mother, and (5) an emotional bridge. The positive relationship with midwives enhanced the women's mental well-being through allowing the women to attune to the peaceful mind which directed their future perspectives and sustained them in motherhood. They became confident mothers by trusting their midwives. The maternity care system in Japan needs to shift to more relationship-based care to ensure continuity of midwifery care that will improve women's birth experiences and their long-term well-being.

Seeking a connection: Women's lived experience of the woman-midwife relationship in mainstream maternity services in Japan.

PROBLEM: In Japan, women continue to suffer from mental health and other postpartum issues despite good clinical outcomes of maternity care. BACKGROUND: As key care providers, midwives potentially affect women's overall birth experience. Most women in Japan give birth in hospitals or obstetric clinics where different midwives and nurses provide one woman with fragmented care. Women's lived experiences of the woman-midwife in these birth facilities are not well known in Japan. AIM: To understand women's birth experience and relationship with midwives in the mainstream maternity care system in Japan to improve maternity care and women's birth experience. METHODS: Face-to-face individual interviews with 14 mothers were conducted. The data were analysed using van Manen's hermeneutic phenomenological approach, which reveals the meaning of human experience in the everyday world. FINDINGS: Four themes were derived from the hermeneutic phenomenological analysis; 1) Closed hearts and bodies in insecure relationships, 2) Alienation, 3) Hopelessness and helplessness, and 4) Women's vulnerability and desire for positive relationships. DISCUSSION: In institutionalised and fragmented maternity care settings, it is difficult for women and midwives to develop a relationship. In such a care environment, women's birth experience with midwives is negative or even traumatic; yet, women still need and seek the midwife relationship. Respectful care-necessary for women's positive birth experience-requires positive relationship between women and midwives. CONCLUSION: Women's negative birth experience may affect their mental health and parenting. Maternity and midwifery care in Japan needs to develop relationship-based care to improve women's birth experience.

Communication technology practices used by midwives with pregnant women/people in Aotearoa New Zealand to ensure quality maternal and newborn care.

INTRODUCTION: Communication technology such as texting is commonly used for sending appointment reminders and reinforcing health messages. Midwives have identified concerns with privacy of information or information taken out of context within an online format. How this technology is used to ensure quality maternal care within a continuity model of midwifery care is unknown. AIM: To describe midwives' experiences of using communication technology with pregnant women/people in Aotearoa New Zealand. METHODS: A mixed methods design was used to collect online survey data from Lead Maternity Carer midwives. Recruitment was through closed midwifery Facebook groups in Aotearoa New Zealand. Survey questions were informed by the Quality Maternal & Newborn Care framework & findings and an integrative literature review. Quantitative data was analysed using descriptive statistics, and qualitative comments analysed using thematic analysis. FINDINGS: 104 midwives responded to the online survey. Phone calls, texting and emails were commonly used by midwives to reinforce health messages and decision making. Communication technology supported, and enhanced relationships midwives develop with their pregnant clients. Texting enhanced documentation of care and enabled midwives to work efficiently. Midwives, however identified concerns when managing expectations around urgent and non-urgent communication. DISCUSSION: Midwives are bound by regulations to ensure they provide safe care to pregnant women/people. Negotiating and understanding expectations around use of communication technology is vitally important to ensure that communications and connections are undertaken in a safe manner.

A historical narrative of the development of midwifery education in Indonesia.

AIM: To describe the history of midwifery education, present the current education programmes and explore the ways that have been undertaken to advance the midwifery profession in Indonesia. METHODS: Historical and contemporary government documents were reviewed. FINDINGS: The history of midwifery education in Indonesia shows a complex picture during and since colonisation with government, education institutes and association proposing different ways in which midwives were to be educated. Advocacy from the midwifery profession in Indonesia meant increasingly it is midwives who are determining how midwifery education is provided. Recent initiatives have resulted in a diploma, advanced diploma, bachelor's degree, and a master's degree in midwifery. The work of the midwifery profession advocating for midwifery education culminated in the Midwifery Act 2019. These changes in this Act will ensure that midwifery education meets the needs of women and their families but also lead to competent midwives who have the knowledge and skills to provide midwifery services at all levels of health provision. The history of midwifery in Indonesia illustrates the importance of the ICM pillars of association, regulation, and education. CONCLUSION: The history of midwifery education in Indonesia shows that for too long midwifery education was decided, determined and even regulated by authorities and disciplines other than midwifery. However, when the midwifery association and regulation inform and regulate midwifery education then there is an opportunity to provide care that will make a difference in outcomes for women and their families. The historical analysis of the story of Indonesia midwifery gives insight into what is required for quality education.

Gaining insight from future mothers: A survey of attitudes and perspectives of childbirth.

OBJECTIVE: To determine whether participant characteristics and/or birth preferences of future mothers are associated with a fear of birth. DESIGN: A cross-sectional survey was used to determine if fear of birth could be profiled in specific participant characteristics and birth choices. SETTING: Urban New Zealand university. PARTICIPANTS: A convenience sample of women (final n = 339) who were < 40 years old, attending university, not pregnant nor had been pregnant but wished for at least one child in the future. FINDINGS: Multivariable analysis identified a subset of four variables that were independently associated with the instrument Childbirth Fear Prior to Pregnancy (CFPP) measuring fear of birth (mean CFPP=38.0, SE=10.1). Preferences of birth by caesarean section (n=32, mean CFPP=44.3, SE=1.8, p < 0.0001), use of epidural analgesia (n=255, mean CFPP=45.0, SE=1.1, p < 0.0001), participants born outside of New Zealand (n=123, mean CFPP=42.9, SE=1.4, p < 0.0001), and participants who scored > 20 ('severe') for depression on DASS-21 scale (n=11, mean CFPP=44.8, SE=1.7, p < 0.0001) were all positively associated with CFPP. Post-hoc analyses revealed that mean CFPP was higher for those that perceived birth technologies as easier, safer, necessary, and required. CONCLUSIONS: Women born outside of New Zealand and/or suffering 'severe' depression were more likely to have a fear of birth. Fear of birth was associated with the participants choices towards medicalised childbirth. Familiarising women with the provision of maternity care in New Zealand and identifying mental health status early could reduce fear of birth and possibly support the vaginal birth intentions of future parents.

The un-silencing of Japanese women's voices in maternity care: A hermeneutic phenomenological study of the woman-midwife relationship.

OBJECTIVE: The purpose of this article is to understand the meaning of the woman-midwife relationship, with the overall aim to improve maternity care and women's birth experiences in Japan. To better understand the meaning of the woman-midwife relationship, this article presents women's and midwives' experiences of having or not having a voice in maternity care. RESEARCH DESIGN: Hermeneutic phenomenology, as described by Max van Manen, helped to uncover the meaning of the phenomenon-the woman-midwife relationship-through participants' lived experience. Individual interviews were conducted with 14 women and 10 midwives living in Japan. The interview data were interpreted and thematically analysed to reveal the meaning of the woman-midwife relationship. FINDINGS: 'Having a voice' emerged as a central theme underpinning the meaning of the woman-midwife relationship; aspects of which included, 1) being unheard, 2) losing a voice, 3) having a voice, and 4) midwives speaking for women. Although having a voice should be a legitimate right for women in maternity care, some women's voices were unheard or lost in the experience with midwives. Conversely, some women gained a voice, especially when they positively and continuously developed their relationship with their midwife. How the woman and the midwife related to each other clearly affected their experience of having a voice in maternity care. KEY CONCLUSION: Having a voice, which portrays dimensions of choice, control, and autonomy, in their own maternity care is vital for women's positive birth experience. The woman-midwife relationship is critical in enabling women to have a voice and midwives to speak for women. Women and midwives need to develop their relationship. Moreover, the maternity care system needs to allow sufficient time and space, for instance, by ensuring midwife continuity of care to develop a positive woman-midwife relationship.

The interplay of structural and external factors for strengthening midwifery education in Indonesia.

OBJECTIVES: This study aimed to identify the barriers to and enablers of the strengthening of midwifery education in Indonesia. Indonesia has a long history of midwifery education. In 1996, midwifery education in Indonesia had a three-year direct-entry pathway leading to a higher education level to meet international standards. The quality of midwifery education is deemed essential for preparing competent midwives. METHODS: A qualitative design was undertaken in 12 midwifery schools in eight cities in six provinces involving 37 participants. Data were gathered using in-depth interviews. Data were analysed using thematic analysis. RESULTS: Several intertwined factors were found to play a vital role in midwifery education. This article focuses on results on "structural and external factors", a theme which contained three sub-themes: "the structures of midwifery programmes", "midwifery accreditation impacts on midwifery education", and "the Midwifery Act". CONCLUSION: The structure of midwifery programmes, the accreditation of midwifery programmes, and establishment of the Midwifery Act contribute to the strengthening of midwifery education in Indonesia. This study highlights the challenges faced and the scheme required to strengthen midwifery education in producing competent newly graduated midwives who improve the midwifery workforce in Indonesia.

Strengthening midwifery education through clinical experience: Findings from a qualitative study in Indonesia.

BACKGROUND: One of the Indonesian Government's strategies to reduce maternal mortality rates has been to place a midwife in every village to provide midwifery care and facilitate essential primary healthcare services. To increase the numbers of midwives, the Indonesian Government began opening midwifery schools. However, Indonesia's maternal mortality rates remained high. This raises the question of the quality of midwifery education in Indonesia and how this education could be strengthened so that midwifery plays a key role in reducing maternal mortality rates. AIM OF THE RESEARCH: The aim of this study was to identify the barriers and enablers to strengthening midwifery education in Indonesia. METHODS: A qualitative descriptive approach and in-depth interviews was the method used with 37 participants from 12 midwifery schools in eight cities situated in six provinces in Indonesia. Indonesian midwives, midwifery lecturers, midwifery students, newly graduated midwives, and obstetricians were interviewed in Bahasa Indonesia. Interviews were transcribed, translated, and thematically analysed following Braun and Clark (2006). FINDINGS: This article focuses on findings on "midwifery clinical experience", a theme which contained four sub-themes: "effective hands-on clinical experience", "theory-practice gap", "role of the mentor in practice", and "the system in the clinical environment". CONCLUSION: This study highlights barriers to preparing midwifery students for obtaining adequate midwifery knowledge and skills during clinical placement. Quality clinical experience would improve knowledge and skills for better preparedness for students to competently meet their role as midwives, contributing to the strengthening of midwifery education in Indonesia.

Development of the Woman-Centred Care Scale- Midwife Self Report (WCCS-MSR).

BACKGROUND: Woman-centred care is recognised as a fundamental construct of midwifery practice yet to date, there has been no validated tool available to measure it. This study aims to develop and test a self-report tool to measure woman-centred care in midwives. METHODS: A staged approach was used for tool development including deductive methods to generate items, testing content validity with a group of experts, and psychometrically testing the instrument with a sample drawn from the target audience. The draft 58 item tool was distributed in an online survey using professional networks in Australia and New Zealand. Testing included item analysis, principal components analysis with direct oblimin rotation and subscale analysis, and internal consistency reliability. RESULTS: In total, 319 surveys were returned. Analysis revealed five factors explaining 47.6% of variance. Items were reduced to 40. Internal consistency (.92) was high but varied across factors. Factors reflected the extent to which a midwife meets the woman's unique needs; balances the woman's needs within the context of the maternity service; ensures midwifery philosophy underpins practice; uses evidence to inform collaborative practice; and works in partnership with the woman. CONCLUSION: The Woman-Centred Care Scale-Midwife Self Report is the first step in developing a valid and reliable tool to enable midwives to self-assess their woman-centredness. Further research in alternate populations and refinement is warranted.

When Maintaining Relationships and Social Connectivity Matter: The Case of New Zealand Midwives and COVID-19.

New Zealand's response to COVID-19 was go hard and go early into Level 4 lockdown on 25th March 2020. This rapid response has resulted in low rates of infection and deaths. For New Zealand midwives, the sudden changes to how they work with women and families during pregnancy, birth and postnatally, especially in the community, required unprecedented innovation and adaptation. The volume of information coming from many different sources, and the speed with which it was changing and updating, added further stress to the delivery of a midwifery model of care underpinned by partnership, collaboration, informed choice, safety and relational continuity. Despite the uncertainties, midwives continued their care for women and their families across all settings. In the rapidly changing landscape of the pandemic, news media provided a real time account of midwives' and families' challenges and experiences. This article provides background and discussion of these events and reports on a content analysis of media reporting the impact on the maternity system in New Zealand during the initial surge of the COVID-19 pandemic. We found that the New Zealand midwife was a major influencer and initiator for relational care to occur uninterrupted at the frontline throughout the COVID-19 lockdown, despite the personal risk. The initial 5-week lockdown in March 2020 involved stringent restrictions requiring all New Zealanders, other than essential workers such as midwives, to remain at home. Midwives kept women, their families and communities central to the conversation throughout lockdown whilst juggling their concerns about keeping themselves and their own families safe. Insights gained from the media analysis suggest that despite the significant stress and upheaval experienced by midwives and wahine/women, relational continuity facilitates quality and consistent care that honors women's choices and cultural needs even during situations of national crisis.

Detection of small for gestational age babies and perinatal outcomes following implementation of the Growth Assessment Protocol at a New Zealand tertiary facility: An observational intervention study.

BACKGROUND: Timely detection of small for gestational age (SGA) fetuses is important for reducing severe perinatal morbidity and mortality, and better tools are needed to detect SGA in maternity care. AIM: We evaluated the effect of the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) in the Counties Manukau Health region, South Auckland, New Zealand, on antenatal detection of SGA and maternal and perinatal outcomes. MATERIALS AND METHODS: Uncontrolled before and after study in women booked under hospital community midwife care with a singleton, non-anomalous pregnancy. Antenatal detection of SGA (birthweight <10th customised centile) was compared pre-GAP (2012, N = 1105) and post-GAP (2017, N = 1082). Composite adverse neonatal outcome was defined as neonatal unit admission >48 h, five-minute Apgar score <7, and/or any ventilation. Analyses were adjusted for maternal age, body mass index, deprivation, smoking and ethnicity. RESULTS: SGA rates were similar across epochs (13.8% vs 12.9%) but antenatal detection of SGA increased from 22.9% (35/153) to 57.9% (81/140) post-GAP (adjusted odds ratio (aOR) = 4.8, 95% CI 2.82-8.18). Rates of induction of labour and caesarean section increased between epochs but were similar in SGA, non-SGA, and detected and non-detected SGA subgroups. Among SGA babies, there was some evidence that antenatal detection of SGA may be associated with lower composite adverse neonatal outcome (detected SGA: aOR 0.44 95% CI 0.17-1.15; non-detected SGA: aOR = 1.81 95% CI 0.73-4.48; interaction P = 0.03). Pre-term birth did not appear to be influenced by GAP. CONCLUSION: Implementation of GAP was associated with a nearly five-fold increase in SGA detection without increasing obstetric intervention for SGA.

Midwifery Job Autonomy in New Zealand: I do it all the time.

INTRODUCTION: This research aimed to identify what supports and what hinders job autonomy for midwives in New Zealand. METHODS: Registered midwives participated in an open-ended, online survey in 2019. Anonymised participants were asked to describe an incident when they felt they were using their professional judgement and/or initiative to make decisions and the resultant actions. The data was analysed thematically. FINDINGS: The participants identified that autonomy is embedded within midwifery practice in New Zealand. Self-employed midwives who provide continuity of care as Lead Maternity Carers, identified they practice autonomously 'all the time'. The relationship with women and their family, and informed decision making, motivated the midwife to advocate for the woman - regardless of the midwife's work setting. Midwifery expertise, skills, and knowledge were intrinsic to autonomy. Collegial relationships could support or hinder the midwives' autonomy while a negative hospital work culture could hinder job autonomy. DISCUSSION: Midwives identified that autonomous practice is embedded in their day to day work. It strengthens and is strengthened by their relationships with the woman/whanau and when their body of knowledge is acknowledged by their colleagues. Job autonomy was described when midwifery decisions were challenged by health professionals in hospital settings and these challenges could be viewed as obstructing job autonomy. CONCLUSION: The high job autonomy that New Zealand midwives enjoy is supported by their expertise, the women and colleagues that understand and respect their scope of practice. When their autonomy is hindered by institutional culture and professional differences provision of woman-centred care can suffer.

A Survey of University Students' Preferences for Midwifery Care and Community Birth Options in 8 High-Income Countries.

INTRODUCTION: Midwifery care is associated with positive birth outcomes, access to community birth options, and judicious use of interventions. The aim of this study was to characterize and compare maternity care preferences of university students across a range of maternity care systems and to explore whether preferences align with evidence-based recommendations and options available. METHODS: A cross-sectional, web-based survey was completed in 2014 and 2015 by a convenience sample of university students in 8 high-income countries across 4 continents (N = 4569). In addition to describing preferences for midwifery care and community birth options across countries, this study examined sociodemographic characteristics, psychological factors, knowledge about pregnancy and birth, and sources of information that shaped students' attitudes toward birth in relation to preferences for midwifery care and community birth options. RESULTS: Approximately half of the student respondents (48.2%) preferred midwifery-led care for a healthy pregnancy; 9.5% would choose to give birth in a birthing center, and 4.5% preferred a home birth. Preference for midwifery care varied from 10.3% among women in the United States to 78.6% among women in the United Kingdom. Preferences for home birth varied from 0.3% among US women to 18.3% among Canadian women. Women, health science students, those with low childbirth fear, those who learned about pregnancy and birth from friends (compared with other sources, eg, the media), and those who responded from Europe were significantly more likely to prefer midwifery care and community birth. High confidence in knowledge of pregnancy and birth was linked to significantly higher odds of community birth preferences and midwifery care preferences. DISCUSSION: It would be beneficial to integrate childbirth education into high school curricula to promote knowledge of midwifery care, pregnancy, and childbirth and to reduce fear among prospective parents. Community birth options need to be expanded to meet demand among the next generation of maternity service users.

Axillary traction: An effective method of resolving shoulder dystocia.

BACKGROUND: At Counties Manukau Health in Auckland, New Zealand, axillary traction is being used when an internal manoeuvre is required for resolution of shoulder dystocia. AIMS: This study presents the outcomes for mother and baby from use of axillary traction and other internal manoeuvres. MATERIALS AND METHODS: Retrospective review of the clinical records of mother and baby for all labours complicated by shoulder dystocia was carried out for an eight-year period. Maternal and neonatal information were compared for the three cohorts of the first internal manoeuvre documented: axillary traction, posterior arm delivery and rotational manoeuvres. RESULTS: There were 226 women who required the use of internal manoeuvres with no significant differences in age, body mass index, parity, ethnicity, diabetes incidence, induction and augmentation of labour rates, length of the first stage and birth weight between the cohorts. Axillary traction was the first internal manoeuvre used for 119 (52.7%) with a success rate of 95.8%. Posterior arm delivery was used first for 49 (21.7%) women with a success rate of 85.7%. Rotational manoeuvres were used first for 58 (25.7%) women with a statistically inferior success rate of 48.3%. There was no significant difference in the maternal and neonatal complication rates between the cohorts. CONCLUSION: Axillary traction has been utilised as the first internal manoeuvre for a large number of women with a higher success rate than other internal manoeuvres without any increase in maternal or neonatal morbidity. It is recommended that this be the first internal manoeuvre attempted when shoulder dystocia occurs.

A cross-country survey of attitudes toward childbirth technologies and interventions among university students.

PROBLEM & AIM: Cultural beliefs that equate birth technology with progress, safety and convenience contribute to widespread acceptance of childbirth technology and interventions. Little is known about attitudes towards childbirth technology and interventions among the next generation of maternity care users and whether attitudes vary by country, age, gender, childbirth fear, and other factors. METHODS: Data were collected via online survey in eight countries. Students who had never had children, and who planned to have at least one child were eligible to participate. FINDINGS: The majority of participants (n=4569) were women (79.3%), and the median age was 22 years. More than half of students agreed that birth technology makes birth easier (55.8%), protects babies from harm (49.1%) and that women have a right to choose a medically non-indicated cesarean (50.8%). Respondents who had greater acceptance of childbirth technology and interventions were from countries with higher national caesarean birth rates, reported higher levels of childbirth fear, and were more likely to report that visual media or school-based education shaped their attitudes toward birth. Positive attitudes toward childbirth technology and interventions were also associated with less confidence in knowledge of birth, and more common among younger and male respondents. DISCUSSION/CONCLUSION: Educational strategies to teach university students about pregnancy and birth in ways that does not frighten them and promotes critical reflection about childbirth technology are needed. This is especially true in countries with high rates of interventions that reciprocally shape culture norms, attitudes, and expectations.

Risk of perinatal mortality in the first year of midwifery practice in New Zealand: analysis of a retrospective national cohort.

OBJECTIVES: To determine whether there was an increased risk of perinatal mortality among mothers booked for care with community lead maternity carer (LMC) midwives in their first compared with later years of practice. DESIGN: Retrospective cohort study using linked national maternity, mortality and workforce data; adjusted analysis using logistic regression. SETTING: New Zealand. PARTICIPANTS: Women under community LMC midwifery care birthing 2008-2014. MAIN OUTCOME MEASURES: Perinatal mortality (stillbirths and neonatal deaths of babies born from 20 weeks' gestation to the 27th day of postnatal life), excluding terminations and deaths associated with congenital abnormalities. RESULTS: There were 2045 deaths among 344 910 births booked with midwives.First year of practice midwives cared for women with higher risk of perinatal mortality, including Maori, Pacific, Indian, <20-year-old mothers, nullipara, smokers, women living in socioeconomic deprivation and with high body mass index, than midwives beyond first year of practice.There was a significant reduction in unadjusted odds of perinatal mortality among women under the care of midwives beyond the first year compared with those within the first year (OR 0.79, 95% CI 0.67 to 0.93) but no significant reduction in risk remained after adjusting for known risk factors, (OR 0.89, 95% CI 0.74 to 1.07).There was a significant increase in the adjusted odds of perinatal mortality among midwives booking a caseload of 15 or fewer mothers per year (1.34, 1.01 to 1.78) and 16 to 30 (1.25, 1.04 to 1.50) compared with midwives booking 51 to 80. CONCLUSIONS: Findings suggest that the first year of midwifery practice is not associated with an increased risk of perinatal mortality but there is evidence that early career midwives are caring for higher-risk women. These findings suggest inequity of access for higher-risk women to experienced midwives and highlight an opportunity to improve support for vulnerable women and new midwives.