Perinatal Outcomes and Level of Labour Difficulty in Deliveries with Right and Left Foetal Position-A Preliminary Study.

BACKGROUND: Many studies have shown the negative influence of the foetus's occiput posterior position during birth on the final perinatal outcome. This study aims to add to the discussion on the impact of foetus positioning on the course of labour and subjective assessment of the level of labour difficulty. METHODS: The cross-sectional study took place from February 2020 to September 2021, and consisted of filling out observation forms and the assessment by the midwives and women of the level of labour difficulty. This study is based on the observation of 152 labours in low-risk women. FINDINGS: When compared to left foetal positioning, labours in which the foetus was in the right position were longer and more frequently failed to progress (in 11.3% vs. 37.5%), and epidural was more frequently administrated (in 30.4% vs. 52.7%). Both women and midwives subjectively evaluated deliveries with a foetus in the right position as more difficult. CONCLUSIONS: The right positioning of the foetus was related to greater labour difficulty and worse perinatal outcomes. The position of the foetus' head in relation to the pelvis should be considered as an indicator of the difficulty of labour and a support plan for the woman should be offered accordingly.

Midwives' experience of personal/professional risk when providing continuity of care to women who decline recommendations: A meta-synthesis of qualitative studies.

PROBLEM: Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines. BACKGROUND: Women's reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives' and their perception of personal/professional risk in such situations. AIM: To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations. METHODS: Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings. FINDINGS: Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women's rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of 'being torn', and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to. CONCLUSION: Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women's right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies.

"I knew there has to be a better way": Women's pathways to freebirth in Poland.

BACKGROUND: Each year a small number of women decide to birth at home without midwifery and medical assistance despite the availability of maternity services in the country. This phenomenon is called freebirth and can be used as a lens to look into shortcomings of maternity care services. AIM: By exploring women's pathways to freebirth, this article aims to examine the larger context of maternity services in Poland and identify elements of care contributing to women's decision to birth without midwifery and medical assistance. METHODS: A qualitative methodology was used employing elements of ethnographic fieldwork, including digital ethnography. Semi-structured interviews with twelve women who freebirth, analysis of online support groups, secondary sources of information and elements of participant observation were used. FINDINGS: Women's decisions to freebirth were born out of their previous negative experiences with maternity care. Persistent use of medical technology and lack of respect from maternity care providers played a major role in pushing women away from available Polish maternity services. While searching for a better environment for themselves and their babies for the subsequent births, women experienced a rigidity of both mainstream and homebirth services and patchy availability of the latter that contributed to their decisions to freebirth. CONCLUSIONS: Freebirth appears to be a consequence of inadequate maternity services both mainstream and homebirth rather than a preference. Women's freebirth experiences can be used to improve maternity care in Poland and inform similar contexts globally.

Midwife experiences of providing continuity of carer: A qualitative systematic review.

PROBLEM: Continuity of carer models present positives and challenges for midwives working in them, and are difficult to sustain. BACKGROUND: Research shows midwifery continuity of carer improves perinatal outcomes and experiences, and is considered the optimal model of care. AIM: To synthesise existing research on midwives' experiences of providing continuity of carer and generate further understanding of what sustains them in practice. METHODS: Protocol for the review was developed using PRISMA guidelines and registered with PROSPERO. 22 studies were included with original themes and findings extracted using JBI tools and synthesised using meta-ethnographic techniques. GRADE CERQual assessment of review findings showed high confidence. FINDINGS: Midwives identified working in continuity of carer models as both fulfilling and challenging. Professional autonomy and ability to develop meaningful relationships were the most commonly cited positives, while lack of work life balance and conflict with the wider maternity team were the main challenges. 15 studies identified strategies employed by midwives which sustained them in practice. DISCUSSION: Midwife experiences of providing continuity are impacted by personal and professional factors. Of paramount importance to sustainability of the model is the support of the wider organisation, and their alignment with principles of person-centred, relational care. CONCLUSION: Relational models of care are desired by midwives, service users and are recommended in policy. Relational models of care must be responsive to midwives needs as well as birthing people, and therefore need to be designed and managed by those working in them and supported by the whole organisation to be sustainable.

New Zealand maternity and midwifery services and the COVID-19 response: A systematic scoping review.

PROBLEM: COVID-19 guidance from professional and health organisations created uncertainty leading to professional and personal stress impacting on midwives providing continuity of care in New Zealand (NZ). The COVID-19 pandemic resulted in massive amounts of international and national information and guidance. This guidance was often conflicting and not suited to New Zealand midwifery. AIM: To examine and map the national and international guidance and information provided to midwifery regarding COVID-19 and foreground learnt lessons for future similar crises. METHODS: A systematic scoping review informed by Arksey and O'Malley's five-stage framework. A range of sources from grey and empirical literature was identified and 257 sources included. FINDINGS: Four categories were identified and discussed: (1) guidance for provision of maternity care in the community; (2) guidance for provision of primary labour and birth care; (3) Guidance for midwifery care to women/wahine with confirmed/suspected COVID-19 infection, including screening processes and management of neonates of infected women/wahine (4) Guidance for midwives on protecting self and own families and whanau (extended family) from COVID-19 exposure. CONCLUSION: Guidance was mainly targeted and tailored for hospital-based services. This was at odds with the NZ context, where primary continuity of care underpins practice. It is evident that those providing continuity of care constantly needed to navigate an evolving situation to mitigate interruptions and restrictions to midwifery care, often without fully knowing the personal risk to themselves and their own families. A key message is the need for a single source of evidence-based guidance, regularly updated and timestamped to show where advice changes over time.

A grounded theory study on midwifery managers' views and experiences of implementing and sustaining continuity of carer models within the UK maternity system.

BACKGROUND: Current UK health policy recommends the transition of maternity services towards provision of Midwifery Continuity of Carer (MCoCer) models. Quality of healthcare is correlated with the quality of leadership and management yet there is little evidence available to identify what is required from midwifery managers when implementing and sustaining MCoCer. AIM: To develop a theoretical framework that represents midwifery managers' experiences of implementing and sustaining MCoCer models within the UK's National Health Service (NHS). METHODS: Charmaz's grounded theory approach was used for this study. Five experienced UK based midwifery managers were interviewed to elicit views and understanding of the social processes underlying the implementation and sustaining of MCoCer. Interviews were transcribed and analysed and focus codes developed into theoretical codes resulting in an emergent core category. FINDINGS: The theoretical framework illustrates the core category 'Leading Meaningful Midwifery'. To manage MCoCer models midwifery managers require a trust and belief in woman centred philosophy of care. They need the skills to focus on non-hierarchical transformational leadership and the courage to assimilate alternative models of care into the NHS. Promoting and protecting the MCoCer model within current services is essential whilst forming a culture based on high quality, safe MCoCer. DISCUSSION: MCoCer models that have sustained within the NHS have had supportive leadership from midwifery managers who have the necessary skills, attitudes, aptitudes and behaviours identified within the findings. Sustainable implementation of MCoCer is achieved through development of a values-based recruitment and retention policy within all areas of midwifery and encouraging midwives with previous experience in MCoCer or supportive philosophies towards it, to manage the model. CONCLUSION: Providing the appropriate support for MCoCer is time consuming and personally demanding for midwifery managers, however, implementing and sustaining MCoCer was shown by participants who valued MCoCer models to be rewarding, bringing meaning to their midwifery leadership.

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.

Spirituality and childbirth: An international virtual co-operative inquiry.

PROBLEM: Medicalised maternity systems do not address spirituality as an aspect of childbirth and its practices of care. Neglecting the spiritual nature of childbirth may negatively affect psychological, emotional and physical wellbeing. BACKGROUND: While there is growing interest in the spiritual side of childbirth there is a paucity of literature on the topic, and hence a lack of understanding generally about how to attend to women's needs for emotional and spiritual support in childbirth. AIM: To collaboratively and through consensus explore ways that spirituality could be honoured in 2st Century maternity care. METHODS: An online co-operative inquiry. Starting with a scoping exercise (N=17) nine co-inquirers continued to Phase One using online discussion boards and seven co-inquirers continued to Phase Two and Three. Co-inquirers were involved in international group work and individual reflective and transformational processes throughout. FINDINGS: Four reflective themes emerged: 'meaning and sense-making'; 'birth culture'; 'embodied relationships and intuition'; and 'space/place/time'. 'Spiritual midwifing' was an overarching theme. There were eight areas of individual transformation and actions concerning spirituality and birth: 1) disseminating inquiry findings; 2) motivating conversations and new ways of thinking; 3) remembering interconnectedness across time and spaces; 4) transforming relationships; 5) transforming practice; 6) generating reflexivity; 7) inspiring self and others to change, and 8) inspiring creativity. CONCLUSION: Spiritual awareness around birth experience emerges through relationships and is affected by the spatial environment. Spiritual midwifing is a relational approach to birth care that recognises and honours the existential significance and meaningfulness of childbirth.

Association of psychosocial-spiritual experiences around childbirth and subsequent perinatal mental health outcomes: an integrated review.

Background: Perinatal mental health is a concern for women, families, communities and maternity care providers internationally. However, there is little understanding of poor perinatal maternal mental health and association with women's experiences of childbirth. Further understanding of psychosocial-spiritual experiences in childbirth and subsequent perinatal mental health is required.Aim: Systematically identify and synthesise the range of evidence available on psychosocial-spiritual experiences around childbirth and foreground possible associations with subsequent perinatal mental health outcomes.Method: Integrated analysis of a range of literature types was undertaken. A comprehensive search strategy was created, and nine databases were searched from 2000 to 2018. Defined inclusion and exclusion criteria were applied independently by two reviewers. Critical appraisal was carried out independently by two reviewers and a third reviewer to resolve differences. The Ecology of Childbirth conceptual framework guided the review.Findings: Six articles were included and four synthesised themes were developed: relationships and kinship matter; significance of childbirth and spiritual experiences; honouring spiritual growth and well-being; and physical manifestations and embodiment. Discussion of the themes using the Ecology of Childbirth framework highlight new perspectives and reveal phenomena lying within and beyond childbirth experiences that may influence perinatal mental health. A new conceptual model is proposed.Conclusions: New insights highlight a paucity of research in the area of perinatal mental health and psychosocial-spiritual childbirth experiences. Further research needs to include postnatal mood disorders and the possible associations with psychosocial-spiritual experiences.

Developing and introducing a post birth care plan (PBCP): An action research project.

OBJECTIVE: There is ongoing poor evaluation of post-birth care and an urgent need to improve women's satisfaction. To develop and evaluate an acceptable and useable post-birth care plan template through collaboration with women and community midwives. DESIGN: Qualitative methodology using an action research design. SETTING AND PARTICIPANTS: North East Scotland. 10 pregnant women and 6 community midwives. FINDINGS: Seven themes emerged from thematic analysis that informed the format of the PBCP template: being prepared for transitions, physical needs, psychosocial needs, cultural, religious and spiritual needs, organisation of care information, knowledge transfer, financial information and guidance. KEY CONCLUSIONS: Women and midwives recognised the benefit of using a PBCP to ensure all information is covered and that care is individualised and organised according to cultural, social and physical needs, especially when there is fragmentation of services. The open conversational style of the PBCP provides opportunity to explore post-birth needs and how they develop over time. IMPLICATIONS FOR PRACTICE: PBCPs provide an opportunity for women to explore their post-birth needs with their midwife, enabling them to have meaningful, respectful conversations with their midwives during the antenatal and post-birth period. This has the potential to increase women's satisfaction with their care and is particularly pertinent in regions where fragmentary systems of care are prevalent.

Is there respectful maternity care in Poland? Women's views about care during labor and birth.

BACKGROUND: Abuse against women in labor starts with subtle forms of discrimination that can turn into overt violence. Therefore it is crucial to work towards prevention and elimination of disrespect and ill-treatment in medical facility perinatal care in which staff allows such abuse. The aim of the study was to analyze the experiences of women related to perinatal care. Special emphasis was put on experiences that had traits indicating disrespectful and offensive care during childbirth in medical facilities providing perinatal care. METHODS: This was a cross-sectional survey. A questionnaire was prepared for respondents who gave birth in medical facilities. Information about the study was posted on the website of a non-governmental foundation dealing with projects aimed at improving perinatal care. The respondents gave online consent for processing the submitted data. 8378 questionnaires were submitted. The study was carried out between February 06 and March 20, 2018. The results were analyzed using the Chi-square independence test. The analysis was carried out at the significance level of 0.05 in Excel, R and SPSS. RESULTS: During their hospital stay, 81% of women in the study experienced violence or abuse from medical staff on at least one occasion. The most common abuse was having medical procedures without prior consent. Inappropriate comments made by staff related to their own or a woman's situation were reported in 25% of situations, whilst 20% of women experienced nonchalant treatment. In the study 19.3% of women reported that the staff did not properly care for their intimacy and 1.7% of the respondents said that the worst treatment was related to feeling anonymous in the hospital. CONCLUSIONS: The study shows that during Polish perinatal care women experience disrespectful and abusive care. Most abuse and disrespect involved violation of the right to privacy, the right to information, the right to equal treatment, and the right to freedom from violence. The low awareness of abuses and complaints reported in the study may result from women's ignorance about relevant laws related to human rights.

Supporting rural midwifery practice using a mobile health (mHealth) intervention: a qualitative descriptive study.

INTRODUCTION: Hypertensive disorders in pregnancy account for 12% of all maternal deaths globally. The risks of suboptimal outcomes from these disorders might be greater in rural and remote locations. These potential risks might be related to poor intra- and interprofessional communications due to geographic and digital isolation. Studies in low- and middle-income countries suggest that improving communications is essential and that mobile health (m-health) interventions can improve outcomes. However, for such interventions to be successful they must involve midwives in any design and software development. This study explored how an m-health intervention might support midwives in the management of women with pre-eclampsia in Scottish rural and remote locations. METHODS: A qualitative descriptive approach was adopted. Rural and remote practising community midwives (n=18) were recruited to participate in three focus groups. The data were gathered through digital recordings of conversations at these focus groups. Recordings were transcribed and thematically analysed. Themes were agreed by consensus with the research team in an iterative process. RESULTS: Five principal themes were identified: 'working in isolation', 'encountering women with pre-eclampsia in rural and remote settings', 'learning on the move', 'using audio-visual resources' and 'unease with advances in technology'. CONCLUSION: Geographic and digital isolation pose significant challenges to rural midwifery practice in a high income country such as Scotland. Midwives need to be involved in the development of m-health interventions for them to be acceptable and tailored to their needs in a rural and remote context. The study highlights how m-health interventions can support continuous professional development whilst on the move with no internet connectivity. However, pride in current practice and unease with advances in mobile technology are barriers to the adoption of an m-health intervention. M-health interventions could be of value to other specialised healthcare practitioners in these regions, including general practitioners, to manage women with complications in their pregnancies.

Phenomenology as a political position within maternity care.

In this article, the authors use the context of childbirth to consider the power that is endemic in certain forms of evidence within maternity care research. First, there is consideration of how the current evidence hierarchy and experimental-based studies are the gold standard to determine and direct women's maternity experiences, although this can be at the detriment of care and irrespective of women's needs. This is followed by a critique of how the predominant means to assess women's experiences via satisfaction surveys is of limited utility, offering impartial and restricted insights to assess the quality of care provision. A counter position of hermeneutic phenomenology as research method is then described. This approach offers an alternative perspective by penetrating the taken-for-granted ordinariness of an event (such as childbirth) to elicit rich emic meanings. Whilst all approaches to understanding maternity care have a place, depending on the question(s) being asked, the contribution of phenomenology is how it can uncover a depth of contextual understanding into what matters to women and to inform and transform care delivery.

Policy, evidence and practice for post-birth care plans: a scoping review.

BACKGROUND: Postnatal care continually attracts less attention than other parts of the childbirth year. Many regions consistently report poor maternal satisfaction with care in the post-birth period. Despite policy recommending post-birth planning be part of maternity services there remains a paucity of empirical evidence and reported experience using post-birth care plans. There is a need to report on post-birth care plans, identify policy and guideline recommendations and gaps in the current empirical research, as well as experiences creating and using post-birth care plans. METHODS: This scoping review accessed empirical literature and government and professional documents from 2005 to present day to build a picture of current understanding of policy imperatives and existent published empirical evidence. The review was informed by the Arksey and O'Malley approach employing five stages. RESULTS: The review revealed that post-birth care planning is promoted extensively in health policy and there is emergent evidence for its implementation. Yet there is a paucity of practice examples and only one evaluation in the UK. The review identified four overarching themes: 'Positioning of post-birth care planning in policy; 'Content and approach'; 'Personalised care and relational continuity'; Feasibility and acceptability in practice'. CONCLUSIONS: Empirical evidence supports post-birth care planning, but evidence is limited leaving many unanswered questions. Health care policy reflects evidence and recommends implementation of post-birth care plans, however, there remains a paucity of information in relation to post-birth care planning experience and implementation in practice. Women need consistent information and advice and value personalised care. Models of care that facilitate these needs are focused on relational continuity and lead to greater satisfaction. It remains unclear if a combination of post-birth care planning and continuity of carer interventions would improve post-birth outcomes and satisfaction. Gaps in research knowledge and practice experience are identified and implications for practice and further research suggested.

Migrant Polish women overcoming communication challenges in Scottish maternity services: A qualitative descriptive study.

BACKGROUND: Migrant women are more likely to experience sub-optimal maternity outcomes and are often described in a problematised way. Communication is crucial in maternity and can be compromised if the language of that service is delivered in a language incomprehensible to migrant women. METHODS: Qualitative descriptive study using 9 in-depth individual interviews with Polish women who recently had experience of local maternity services. Recorded interviews were transcribed and thematically analysed. A salutogenic conceptual framework was adopted for data analysis. FINDINGS: Three descriptive themes: 'Communication and understanding', 'Relationships matter' and Values and expectations'. Seven related subthemes where identified. DISCUSSION: Vulnerability in this study is understood as uncertainty, risk and emotional exposure to situations that are not understandable. Applying a salutogenic lens to analysis reveals the significance of quality communication, relationship and culturally sensitive practices as ways of mitigating feelings of vulnerability in the host country. Antonovski's Sense of Coherence' (SoC) highlights migrant women's ability to comprehend and capacity to understand their unique experiences of communication challenges. Participant's psychosocial, cultural, and individual beliefs reveal an ability to trust maternity systems that are different from their own cultural values and help them move towards a Sense of Coherence (SOC) and face their vulnerability. CONCLUSION: Working with migrant women requires a salutary focus. Maternity care professionals involved in the care of this population need to consider individual internal and external resources and avoid treating migrant women as a problematic group. Maternity care provision needs to acknowledge migrant women's strengths, values and expectations and adapt local services. This is done by addressing individual woman's needs through a salutary focus, person-centredness and a system of care that values relationships and social connectedness.

Joys and challenges of relationships in Scotland and New Zealand rural midwifery: A multicentre study.

BACKGROUND: Globally there are challenges meeting the recruitment and retention needs for rural midwifery. Rural practice is not usually recognised as important and feelings of marginalisation amongst this workforce are apparent. Relationships are interwoven throughout midwifery and are particularly evident in rural settings. However, how these relationships are developed and sustained in rural areas is unclear. AIM: To study the significance of relationships in rural midwifery and provide insights to inform midwifery education. METHODS/DESIGN: Multi-centre study using online surveys and discussion groups across New Zealand and Scotland. Descriptive and template analysis were used to organise, examine and analyse the qualitative data. FINDINGS: Rural midwives highlighted how relationships with health organisations, each other and women and their families were both a joy and a challenge. Social capital was a principal theme. Subthemes were (a) working relationships, (b) respectful communication, (c) partnerships, (d) interface tensions, (e) gift of time facilitates relationships. CONCLUSIONS: To meet the challenges of rural practice the importance of relationship needs acknowledging. Relationships are created, built and sustained at a distance with others who have little appreciation of the rural context. Social capital for rural midwives is thus characterised by social trust, community solidarity, shared values and working together for mutual benefit. Rural communities generally exhibit high levels of social capital and this is key to sustainable rural midwifery practice. IMPLICATIONS: Midwives, educationalists and researchers need to address the skills required for building social capital in rural midwifery practice. These skills are important in midwifery pre- and post-registration curricula.

The significance of interfamilial relationships on birth preparedness and complication readiness in Pakistan.

BACKGROUND: In the interests of improving maternal health care and survival, the issue of birth preparedness and complication readiness has been much debated and has remained a priority for the international health community. The provision of birth preparedness and complications readiness is determined by a range of different factors. AIM: The main aim of this study is to identify and measure the influence of husbands and other family relationships on birth preparedness and complications readiness in the Khyber Pakhtunkhwa province of Pakistan. METHODS: This study is a cross-sectional exploratory study. Data was collected through a survey questionnaire. Logistic regression and descriptive analysis was used. FINDINGS: Analysis indicated that the mother-in-law's role, men's and women's level of education and interfamilial relationships are still the most significant factors influencing birth preparedness and complications readiness. Of the respondents, 86% were receiving antenatal care and 76.5% were planning for the birth to take place in state-run hospitals or private obstetric and gynae clinics. CONCLUSION: The tendency to take up antenatal care in Khyber Pakhtunkhwa can mainly be credited to a mutual understanding between husband and wife and a good relationship between the woman and her mother-in-law. Highlighting the significance of these relationships has implications for ensuring birth preparedness and complications readiness.

'Living the rural experience-preparation for practice': The future proofing of sustainable rural midwifery practice through midwifery education.

Rural practice presents unique challenges and skill requirements for midwives. New Zealand and Scotland face similar challenges in sustaining a rural midwifery workforce. This paper draws from an international multi-centre study exploring rural midwifery to focus on the education needs of student midwives within pre-registration midwifery programmes in order to determine appropriate preparation for rural practice. The mixed-methods study was conducted with 222 midwives working in rural areas in New Zealand (n = 145) and Scotland (n = 77). Midwives' views were gathered through an anonymous online survey and online discussion forums. Descriptive analysis was used for quantitative data and thematic analysis was conducted with qualitative data. 'Future proofing rural midwifery practice' using education was identified as the overarching central theme in ensuring the sustainability of rural midwives, with two associated principle themes emerging (i) 'preparation for rural practice' and (ii) 'living the experience and seeing the reality'. The majority of participants agreed that pre-registration midwifery programmes should include a rural placement for students and rural-specific education with educational input from rural midwives. This study provides insight into how best to prepare midwives for rural practice within pre-registration midwifery education, in order to meet the needs of midwives and families in the rural context.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland.

OBJECTIVE: the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN: online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS: 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS: underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS: rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE: findings will inform the preparation of midwives for rural midwifery practice.