Global Health Update: World Health Assembly Focuses on Public Health.

Resolutions include strengthening access to nurse midwives in underserved areas.

Trusting My Instincts to Protect Mothers.

A nurse-midwife describes how she had to trust her instincts when she suspected a woman was in danger.

Project 20: Midwives' insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how.

INTRODUCTION: Continuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. OBJECTIVE: To explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women's outcomes. DESIGN: Realist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FINDINGS: Three main themes were identified: 'Perceptions of the model of care, 'Tailoring the service to meet women's needs', 'Going above and beyond'. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women's outcomes, and how women with different social risk factors respond to these mechanisms. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Overall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women's outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Discourses and critiques of breastfeeding and their implications for midwives and health professionals.

This article is a discussion of the recently emerging critique of pro-breastfeeding discourses in academic literature, and what this means for midwives and other professionals who find themselves promoting breastfeeding because of professional expectations or indeed workplace policies. Various strands in the debate are explored, starting with dominant and familiar 'evidence' and descriptions of breastfeeding and breastmilk that are carried through to international policies that advocate breast over formula feeding. We then consider evidence predominantly from social science literature that has found some women's experiences of infant feeding to be at variance with the dominant pro-breastfeeding ideology. We argue that midwives and others delivering maternity care are the means to deliver the policy aspirations contained in the World Health Organization (WHO, 2018) Baby Friendly Hospital Initiative document that makes selective positive claims about breastfeeding without adequately considering its potential drawbacks. We conclude that although the benefits of breastfeeding tend to be exaggerated in promotional material, on balance the weight of evidence still favours breast over formula feeding. We challenge the charge that breastfeeding jeopardises women's financial position by arguing that it is not breastfeeding per se that impacts negatively on women's economic prospects, but rather the way in which society is socially organised.

A Survey of Midwives' Attitudes Toward Men in Midwifery.

INTRODUCTION: The midwifery profession in the United States demonstrates a significant lack of diversity. The critical need to address the lack of racial and ethnic diversity in the midwifery workforce is well recognized; little attention, however, has been given to gender diversity. This study focused on gender diversity within midwifery, specifically with regard to men who are midwives. Nearly 99% of midwives in the United States are women. No research has previously explored the attitudes of the predominantly female midwifery workforce toward its male members. METHODS: An invitation to an internet survey was sent to the American College of Nurse-Midwives (ACNM) membership. Quantitative and open-ended questions assessed attitudes toward and experiences with male midwives, whether members thought men belong in the profession, whether gender impacts quality of care, if ACNM should facilitate gender diversification, and whether exposure to male midwives impacts attitudes toward gender diversification. Data analysis of qualitative responses used a qualitative description methodology to identify common themes. RESULTS: Six thousand, nine hundred sixty-five surveys were distributed, and 864 participants completed the survey. Respondents reported beliefs that men belong in midwifery (71.4%), that gender does not affect quality of care (74%), and that ACNM should support gender diversity (72%). Respondents' perspectives revealed 3 dichotomous themes pertaining to the core nature of midwifery and how men fit within the profession: 1) inclusion versus exclusion, 2) empowerment versus protection, and 3) sharing with versus taking from. Often, the same respondent expressed both aspects of the dichotomy simultaneously. DISCUSSION: This study contributes new information about midwives' attitudes and beliefs toward gender diversity in midwifery in the United States. The values of professionalism, tradition, feminism, protection, and diversification inform participant responses. Findings support efforts toward gender diversification and have implications for implementation in education and practice.

Looking toward 2030: Strengthening midwifery education through regional partnerships.

AIMS: The purpose of this paper is to describe the impact of a regional capacity-building project between Thailand and Laos that supports the United Nation's sustainable development goal 3 through midwifery education. DESIGN: Discussion paper based on an exemplar. DATA SOURCES: The International Confederation of Midwifery's standards of midwifery education and World Health Organization midwifery educator core competencies provided the framework for capacity-building of Lao midwifery educators. IMPLICATIONS FOR NURSING: Knowledge gained from this 2-year project (October 2015-November 2017) increased the teaching confidence of midwifery educators while linking international standards and competencies to curriculum revision. In addition, capacity-building projects based on a needs assessment and implementation from regional partners may result in policy changes at the local and national level. CONCLUSION: Partnerships are essential to meeting the sustainable development goals. These regional partnerships may be highly effective in creating sustainable capacity-building projects. IMPACT: Maternal mortality and preventing deaths of children under 5 years old continues to be a challenge across the globe despite progress made in recent years. Progress toward sustainable development goal 3, requires efforts addressed in sustainable development goal17, partnership. Laos has one of the highest maternal mortality rates in Southeast Asia. A project to increase capacity of midwifery educators demonstrated the benefit of regional partnerships in Laos to have an impact on sustainable development goal 3 ultimately improving maternal outcomes throughout the country. Partnerships especially those between countries in the same region, are crucial to the success of meeting the sustainable development goals.

Knowledge of US Midwifery Credentials Among Members of the American College of Nurse-Midwives.

INTRODUCTION: Three midwifery credentials are granted in the United States: certified nurse-midwife (CNM), certified midwife (CM), and certified professional midwife (CPM). Confusion about US midwifery credentials may restrict growth of the midwifery profession. This survey assessed American College of Nurse-Midwives (ACNM) members' knowledge of US midwifery credentials. METHODS: ACNM members (N = 7551) were surveyed via email in 2017. The survey asked respondents to report demographic information and to identify correct statements about the education, certification, and scope of practice of CNMs, CMs, and CPMs. Responses to 17 items about all midwives certified in the United States, a 5-item subset specific to CNMs/CMs, and one item related to location of midwifery practice by credential were analyzed. RESULTS: Nearly a quarter of the membership (22.1%) responded to the survey. Higher scores on the survey indicated greater identification of correct statements about the education, certification, scope, and location of practice of CNMs, CMs, and CPMs. Significant differences in scores were found among ACNM members based on their level of education, degree of professional involvement in midwifery, and prior practice as a nurse. ACNM members with higher scores on the survey held a doctorate, worked in Region I, and had greater professional leadership involvement in midwifery organizations. Participants with less nursing experience prior to their midwifery education also scored significantly higher on the survey. DISCUSSION: Although two-thirds of respondents correctly answered items on the preparation, credentialing, and scope of practice of CNMs, CMs, and CPMs, a significant minority had gaps in knowledge. Results of this survey suggest the need for outreach about US midwifery credentials. Future research to replicate and expand upon this survey may benefit the profession of midwifery in the United States.

Motivators and challenges to research recruitment - A qualitative study with midwives.

OBJECTIVE: To explore midwives' experiences of recruiting participants to research studies conducted by other researchers. DESIGN: An inductive qualitative study. METHODS: Individual face-to-face or telephone interviews using a semi-structured interview guide. Interviews were analysed thematically. SETTINGS: One large urban maternity hospital in Ireland. PARTICIPANTS: A purposive sample of 19 midwives FINDINGS: Three co-dependent themes emerged: intrinsic motivations, extrinsic motivations and challenges. Intrinsic motivations included midwives' personal beliefs about the value of research in general, its potential to improve practice, and their perceptions of how robust a particular study was and how it might impact on an individual woman and her baby. This included an inherent desire to shield some women, those who were perceived to have ongoing health issues or be anticipating a sub-optimal pregnancy outcome, from being offered study information. Extrinsic motivations related to the complexity of a research study and a specific researcher's characteristics. Challenges to offering potential participants research study information and, therefore, to successful recruitment included time constraints, workload and the volume of research being conducted simultaneously. KEY CONCLUSIONS: Participants navigated the two, sometimes competing, worlds of clinical practice and clinical research. Set in the context of workload and the volume of research being conducted simultaneously, midwives' perceptions of a study's robustness, clarity, its potential impact on individual women and ability to improve practice governed their motivation to offer information on research studies to potential participants. IMPLICATIONS FOR PRACTICE: Inviting clinicians to assess the study information may improve its clarity and create opportunities to discuss the potential value and recruitment bias. Researchers should be available to address clinicians' questions about particular research studies. At an organisational level, a system for managing the volume of research activity is required.

`It makes sense and it works': Maternity care providers' perspectives on the feasibility of a group antenatal care model (Pregnancy Circles).

AIM: To test the feasibility of introducing a group antenatal care initiative (Pregnancy Circles) in an area with high levels of social deprivation and cultural diversity by exploring the views and experiences of midwives and other maternity care providers in the locality before and after the implementation of a test run of the group model. DESIGN: (i) Pre-implementation semi-structured interviews with local stakeholders. (ii) Post-implementation informal and semi-structured interviews and a reflective workshop with facilitating midwives, and semi-structured interviews with maternity managers and commissioners. Data were organised around three core themes of organisational readiness, the acceptability of the model, and its impact on midwifery practice, and analyzed thematically. SETTING: A large inner-city National Health Service Trust in the United Kingdom. PARTICIPANTS: Sixteen stakeholders were interviewed prior to, and ten after, the group model was implemented. Feedback was also obtained from a further nine midwives and one student midwife who facilitated the Pregnancy Circles. INTERVENTION: Four Pregnancy Circles in community settings. Women with pregnancies of similar gestation were brought together for antenatal care incorporating information sharing and peer support. Women undertook their own blood pressure and urine checks, and had brief individual midwifery checks in the group space. FINDINGS: Dissatisfaction with current practice fuelled organisational readiness and the intervention was both possible and acceptable in the host setting. A perceived lack of privacy in a group setting, the ramifications of devolving blood pressure and urine checks to women, and the involvement of partners in sessions were identified as sticking points. Facilitating midwives need to be adequately supported and trained in group facilitation. Midwives derived accomplishment and job satisfaction from working in this way, and considered that it empowered women and enhanced care. KEY CONCLUSIONS: Participants reported widespread dissatisfaction with current care provision. Pregnancy Circles were experienced as a safe environment in which to provide care, and one that enabled midwives to build meaningful relationships with women. IMPLICATIONS FOR PRACTICE: Pre-registration education inadequately prepared midwives for group care. Addressing sticking points and securing management support for Pregnancy Circles is vital to sustain participation in this model of care.

Antidepressants during pregnancy: Guideline adherence and current practice amongst Dutch gynaecologists and midwives.

BACKGROUND AND OBJECTIVES: prescription rates of antidepressants during pregnancy range from 2-3% in The Netherlands to 6.2% in the USA. Inconclusive evidence about harms and benefits of antidepressants during pregnancy leads to variation in advice given by gynaecologists and midwives. The objective was to investigate familiarity with, and adherence to the Dutch multidisciplinary guideline on Selective Serotonin Reuptake Inhibitor (SSRI) use during pregnancy by gynaecologists and midwives in the Netherlands. METHODS: an online survey was developed and send to Dutch gynaecologists and midwives. The survey consisted mainly of multiple-choice questions addressing guideline familiarity and current practice of the respondent. Also, caregiver characteristics associated with guideline adherence were investigated. FINDINGS: a total of 178 gynaecologists and 139 midwives responded. Overall familiarity with the Dutch guideline was 92.7%. However, current practice and advice given to patients by caregivers differed substantially, both between gynaecologists and midwives as well as within both professions. Overall guideline adherence was 13.9%. Multivariable logistic regression showed that solely caregiver profession was associated with guideline adherence, with gynaecologists having a higher adherence rate (OR 2.10, 95%CI 1.02-4.33) than midwives. KEY CONCLUSION: although reported familiarity with the guideline is high, adherence to the guideline is low, possibly resulting in advice to patients that is inconsistent with guidelines and unwanted variation in current practice. IMPLICATIONS FOR PRACTICE: further implementation of the recommendations as given in the guideline should be stimulated. Additional research is needed to examine how gynaecologists and midwives can be facilitated to follow the recommendations of the clinical guideline on SSRI use during pregnancy.

Contribuição da enfermeira obstétrica nas boas práticas da assistência ao parto e nascimento / Contribución de la enfermera obstétrica en buenas prácticas de asistencia departo y nacimiento / Contribution of obstetric nurse in good practices of childbirth and birth assistance

Objectives: identify the good practices developed by Obstetric Nurse in a Municipal Maternity of Rio de Janeiro and analyze the assistance of Nurses in Obstetric practice in the time of delivery. Method: Documentary study, which was conducted in a maternity ward of the city of Rio de Janeiro from January to July 2015. The study was sent to Brazil Platform and the report released with CAAE number: 51008015.0.0000.5285. Results: It was found that Obstetric nurses offered assistance to 367 parturient women using good practice safely. The study showed that the use of good practices has great influence on maternal physiology, in newborn adaptation and reduction of anemia in early childhood. Conclusion: It is assistance in good obstetric practices in childbirth and birth of humanized form and in the context of scientific evidence as follows the recommendations of the Ministry of Health.

Objetivos: identificar as boas práticas desenvolvidas pela Enfermeira Obstétrica em uma Maternidade Municipal do Rio de Janeiro e analisar a assistência das Enfermeiras Obstétricas nas Boas Práticas no momento do parto. Método: Estudo documental, que foi realizado em uma maternidade municipal da cidade do Rio de Janeiro no período de janeiro a julho de 2015.O estudo foi encaminhado à Plataforma Brasil e o Parecer liberado com o nº CAAE: 51008015.0.0000.5285. Resultados: Foi constatado que as Enfermeiras Obstétricas ofereceram assistência à 367 parturientes utilizando as boas práticas de forma segura. O estudo demonstrou que o uso das boas práticas tem grande influência na recuperação da fisiologia materna, na adaptação do recém-nascido e redução da anemia na primeira infância. Conclusão: Ocorre a assistência dentro das boas práticas obstétricas no parto e nascimento de forma humanizada e no contexto das evidências científicas como segue as recomendações do Ministério da Saúde.

Objetivos: identificar las buenas prácticas desarrolladas por la enfermera obstétrica en una maternidad Municipal do Rio de Janeiro y analizar la asistencia del personal de enfermería en la práctica obstétrica en el momento del parto. Método: estudio documental, que se llevó a cabo en una sala de maternidad de la ciudad de Rio de Janeiro desde enero a julio de 2015. El estudio fue refiere la Plataforma Brasil y el informe publicado conel número CAAE: 51008015.0.0000.5285. Resultados: se encontró que las enfermeras obstétricas ofrecen asistencia a 367 la mujer parturienta utilizando las mejores prácticas de seguridad. El estudio demostró que el uso de las buenas prácticas tiene gran influencia en la fisiología materna, en la adaptación del recién nacido y la reducción de la anemia y primera infancia. Conclusión: es la asistencia en las buenas prácticas obstétricas en el parto y nacimiento de una manera humanizada y en el contexto las evidencia científicas como sigue las recomendaciones del Ministerio de Salud.

Role development in midwifery education: A place for simulation.

OBJECTIVE: simulation-based learning is increasingly seen as an effective strategy to develop student nurse-midwives into effective healthcare team members. A gap exists concerning the use of simulation to promote role transition/development of the student midwife. The purpose of this paper is to describe an evolving simulation curriculum aimed at role development of the student midwife as well as technical skills training. SETTING: the University of New Mexico, College of Nursing and the Interprofessional Healthcare Simulation Center. PARTICIPANTS: this program involves students enrolled in the Masters in Nursing Program, Midwifery Concentration and students enrolled in the pre-licensure Bachelor of Science in Nursing program. FINDINGS: simulation allows for an opportunity to focus on communication skills with other team members, practicing the importance of clear delegation of responsibilities in high-stress situations. CONCLUSIONS: the value of practicing the necessary communication skills, as well as the opportunity to engage in simulated delegation of tasks, is an important aspect of midwifery role development.

Nurse and midwifery prescribing in Ireland: A scope-of-practice development for worldwide consideration.

For 10 years, select Irish nurses and midwives who pass a rigorous 6 month theory and practical program can prescribe medications and other medicinal products. Given the need for timely, accessible, and affordable health-care services in all countries, this nursing/midwifery education and practice development is worthy of examination. Irish nurse/midwife prescribing occurred following long-term deliberative nursing profession advocacy, nursing education planning, nursing administration and practice planning, interdisciplinary health-care team support and complementary efforts, and government action. A review of documents, research, and other articles was undertaken to examine this development process and report evaluative information for consideration by other countries seeking to improve their health-care systems. Nurse/midwife prescribing was accomplished successfully in Ireland, with the steps taken there to initiate and establish nurse/midwife prescribing of value internationally.

The use of midwife-led primary antenatal care by obese women in The Netherlands: An explorative cohort study.

OBJECTIVE: to study the effect of body mass index (BMI) on the use of antenatal care by women in midwife-led care. DESIGN: an explorative cohort study. SETTING: 11 Dutch midwife-led practices. PARTICIPANTS: a cohort of 4421 women, registered in the Midwifery Case Registration System (VeCaS), who received antenatal care in midwife-led practices in the Netherlands and gave birth between October 2012 and October 2014. FINDINGS: the mean start of initiation of care was at 9.3 (SD 4.6) weeks of pregnancy. Multiple linear regression showed that with an increasing BMI initiation of care was significantly earlier but BMI only predicted 0.2% (R2) of the variance in initiation of care. The mean number of face-to- face antenatal visits in midwife-led care was 11.8 (SD 3.8) and linear regression showed that with increasing BMI the number of antenatal visits increased. BMI predicted 0.1% of the variance in number of antenatal visits. The mean number of antenatal contacts by phone was 2.2 (SD 2.6). Multiple linear regression showed an increased number of contacts by phone for BMI categories 'underweight' and 'obese class I'. BMI categories predicted 1% of the variance in number of contacts by phone. KEY CONCLUSIONS: BMI was not a relevant predictor of variance in initiation of care and number of antenatal visits. Obese pregnant women in midwife-led practices do not delay or avoid antenatal care. IMPLICATIONS FOR PRACTICE: Taking care of pregnant women with a high BMI does not significantly add to the workload of primary care midwives. Further research is needed to more fully understand the primary maternal health services given to obese women.

The Evolving Role of Midwives as Laborists.

This article examines the history and present state of the midwife as laborist. The role of the midwife and obstetrician laborist/hospitalist is rapidly evolving due to the need to improve patient safety and provide direct care due to reduced resident work hours, as well as practice demands experienced by community providers and other factors. Models under development are customized to meet the needs of different communities and hospitals. Midwives are playing a prominent role in many laborist/hospitalist practices as the first-line hospital provider or as part of a team with physicians. Some models incorporate certified nurse-midwives/certified midwives as faculty to residents and medical students. The midwifery laborist/hospitalist practices at Baystate Medical Center in Springfield, Massachusetts, are presented as an example of how midwives are functioning as laborists. Essential components of a successful midwife laborist program include interdisciplinary planning, delineation of problems the model should solve, establishment of program metrics, clear practice guidelines and role definitions, and a plan for sustained funding. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Mix of Maternity Care Providers in Canada.

OBJECTIVE: To identify the factors influencing women's choice of maternity care providers in Canada. METHOD: Using the Maternity Experience Survey and a multinomial logit model, this paper examined the influence of various socio-economic and demographic factors on the mix of maternity care providers, while controlling for maternal risk profiles. Additionally, provinces were interacted with maternal age to assess the extent to which regional variations in mix of maternity care providers is influenced by pregnant women's needs. RESULTS: Besides maternal risk factors, province of prenatal care and the place of residence were found to be statistically significant determinants of choice of maternity care providers. Analysis involving interaction terms indicated wide regional variations in the mix of providers by maternal age. CONCLUSIONS: The results suggest a wide provincial variation in the mix of maternity care providers. New provincial government initiatives are needed to enhance the supply and capacity of care providers.

Trends in Midwifery Use in Manitoba.

OBJECTIVE: To describe the trends in numbers of midwives and midwifery-attended births and the characteristics of women who used midwifery health care services in Manitoba from 2001-2002 to 2009-2010. METHODS: We conducted a quantitative descriptive analysis using population-based, de-identified administrative data from the Population Health Research Data Repository at the Manitoba Centre for Health Policy in Winnipeg, Manitoba to study the use of midwifery care. Trends in the numbers of practising and non-practising midwives were based on data from the College of Midwives of Manitoba registries and its annual reports. RESULTS: There were 132,123 births in Manitoba during this time frame. Of those births, 6326 (4.8%) were midwife-attended births. There was modest growth in the overall proportion of midwife-attended births and in the number of midwives over the 10-year time period. The number of midwife-attended hospital births increased from 308 to 612 between 2001-2002 and 2009-2010, while the number of home births increased from 97 to 127. Most women who received midwifery care were in the 20- to 34-year age group and were multiparous. CONCLUSION: The volume and distribution of midwifery services in Manitoba has slowly increased. The proportion of births attended by midwives continues to fall short of the goals set by the original human resource strategy, which projected that by 2005, 14% of births would be attended by midwives. Further research is needed to analyze the factors that have influenced the growth and sustainability of the midwifery profession in this province.

Objectif : Décrire les tendances en ce qui concerne le nombre de sages-femmes et d'accouchements menés par des sages-femmes, ainsi que les caractéristiques des femmes qui ont eu recours aux services d'une sage-femme au Manitoba pour la période s'étalant de 2001-2002 à 2009-2010. Méthodes : Nous avons mené une analyse descriptive quantitative au moyen de données administratives anonymisées en population générale issues du Population Health Research Data Repository du Manitoba Centre for Health Policy de Winnipeg, au Manitoba, pour étudier l'utilisation des services de sages-femmes. Les tendances quant au nombre des sages-femmes (en pratique ou non) ont été fondées sur des données issues des registres et des rapports annuels du College of Midwives of Manitoba. Résultats : Au cours de la période à l'étude, 132 123 accouchements se sont déroulés au Manitoba, dont 6 326 (4,8 %) ont été menés par des sages-femmes. Nous avons constaté une croissance modeste de la proportion globale des accouchements menés par des sages-femmes et du nombre de sages-femmes au cours de cette période de 10 ans. Le nombre d'accouchements menés par des sages-femmes en milieu hospitalier est passé de 308, en 2001-2002, à 612, en 2009-2010, tandis que le nombre d'accouchements à domicile est passé de 97 à 127. La plupart des femmes qui ont eu recours aux services d'une sage-femme se trouvaient dans le groupe des 20 à 34 ans et étaient multipares. Conclusion : Le volume et la distribution des services de sages-femmes ont connu une croissance progressive au Manitoba. La proportion des accouchements menés par des sages-femmes continue d'être inférieure à l'objectif établi par la stratégie de ressources humaines initiale, laquelle prévoyait que, en 2005, 14 % des accouchements seraient menés par des sages-femmes. La tenue d'autres recherches s'avère requise pour analyser les facteurs qui ont influencé la croissance et la pérennité de la pratique sage-femme dans cette province.