Polygenic risk score adds to a clinical risk score in the prediction of cardiovascular disease in a clinical setting.

BACKGROUND AND AIMS: A cardiovascular disease polygenic risk score (CVD-PRS) can stratify individuals into different categories of cardiovascular risk, but whether the addition of a CVD-PRS to clinical risk scores improves the identification of individuals at increased risk in a real-world clinical setting is unknown. METHODS: The Genetics and the Vascular Health Check Study (GENVASC) was embedded within the UK National Health Service Health Check (NHSHC) programme which invites individuals between 40-74 years of age without known CVD to attend an assessment in a UK general practice where CVD risk factors are measured and a CVD risk score (QRISK2) is calculated. Between 2012-2020, 44,141 individuals (55.7% females, 15.8% non-white) who attended an NHSHC in 147 participating practices across two counties in England were recruited and followed. When 195 individuals (cases) had suffered a major CVD event (CVD death, myocardial infarction or acute coronary syndrome, coronary revascularisation, stroke), 396 propensity-matched controls with a similar risk profile were identified, and a nested case-control genetic study undertaken to see if the addition of a CVD-PRS to QRISK2 in the form of an integrated risk tool (IRT) combined with QRISK2 would have identified more individuals at the time of their NHSHC as at high risk (QRISK2 10-year CVD risk of ≥10%), compared with QRISK2 alone. RESULTS: The distribution of the standardised CVD-PRS was significantly different in cases compared with controls (cases mean score .32; controls, -.18, P = 8.28×10-9). QRISK2 identified 61.5% (95% confidence interval [CI]: 54.3%-68.4%) of individuals who subsequently developed a major CVD event as being at high risk at their NHSHC, while the combination of QRISK2 and IRT identified 68.7% (95% CI: 61.7%-75.2%), a relative increase of 11.7% (P = 1×10-4). The odds ratio (OR) of being up-classified was 2.41 (95% CI: 1.03-5.64, P = .031) for cases compared with controls. In individuals aged 40-54 years, QRISK2 identified 26.0% (95% CI: 16.5%-37.6%) of those who developed a major CVD event, while the combination of QRISK2 and IRT identified 38.4% (95% CI: 27.2%-50.5%), indicating a stronger relative increase of 47.7% in the younger age group (P = .001). The combination of QRISK2 and IRT increased the proportion of additional cases identified similarly in women as in men, and in non-white ethnicities compared with white ethnicity. The findings were similar when the CVD-PRS was added to the atherosclerotic cardiovascular disease pooled cohort equations (ASCVD-PCE) or SCORE2 clinical scores. CONCLUSIONS: In a clinical setting, the addition of genetic information to clinical risk assessment significantly improved the identification of individuals who went on to have a major CVD event as being at high risk, especially among younger individuals. The findings provide important real-world evidence of the potential value of implementing a CVD-PRS into health systems.

Rural and regional maternity managers' and educators' views of the Maternity and Newborn Emergencies (MANE) education program in Victoria, Australia: a qualitative descriptive study.

BACKGROUND: Australia has one of the lowest perinatal morbidity and mortality rates in the world, however a cluster of perinatal deaths at a regional health service in the state of Victoria in 2015 led to state-wide reforms, including the introduction of the Maternity and Newborn Emergencies (MANE) program. MANE was a 2-day interprofessional maternity education program delivered by external expert facilitators to rural and regional Victorian maternity service providers. An independent evaluation found that the MANE program improved the confidence and knowledge of clinicians in managing obstetric emergencies and resulted in changes to clinical practice. While there is a large volume of evidence that supports the use of interprofessional education in improving clinicians' clinical practice, the impact of these programs on the overall safety culture of a health service has been less studied. Managers and educators have an important role in promoting the safety culture and clinical governance of the heath service. The aim of this study, therefore, was to explore Victorian rural and regional maternity managers' and educators' views and experiences of the MANE program. METHODS: Maternity managers and educators from the 17 regional and rural health services across Victoria that received the MANE program during 2018 and 2019 were invited to participate. Semi-structured interviews using mostly open-ended questions (and with a small number of fixed response questions) were undertaken. Qualitative data were transcribed verbatim and analysed thematically. Descriptive statistics were used for quantitative data. RESULTS: Twenty-one maternity managers and educators from the 17 health services participated in the interviews. Overall, participants viewed the MANE program positively. Four themes were identified: the value of external facilitation in providing obstetric emergency training; improved awareness and understanding of clinical governance; improved clinical practice; and the importance of maintaining the program. Participants agreed that MANE had improved the confidence (94%) and skills (94%) of clinicians in managing obstetric emergencies, as well as confidence to escalate concerns (94%), and most agreed that it had improved clinical practice (70%) and teamwork among attendees (82%). CONCLUSION: Maternity managers and educators were positive about MANE; they considered that it contributed to improving factors that impact the safety culture of health services, with delivery by external experts considered to be particularly important. Given the crucial role of maternity managers and educators on safety culture in health services, as well in program facilitation, these findings are important for future planning of maternity education programs across the state. TRIAL REGISTRATION: Trial registration was not required for this study.

Identifying women with a disability in Australian maternity services: Time for a change.

It is estimated that over 1 billion people worldwide have a disability. In Australia, 9% of women of childbearing age have a disability, but data on disability status for women accessing maternity services are not routinely collected and data collection processes are inconsistent. Maternal disability may affect perinatal outcomes, but to understand what factors might be amenable to interventions to improve outcomes, accurate data collection on disability status is essential. This opinion piece reflects on disability identification within maternity services in Australia, identifying areas for policy and practice change.

Accurate identification and documentation of First Nations women and babies attending maternity services: How can we 'close the gap' if we can't get this right?

BACKGROUND: Policies and strategies addressing the health inequities experienced by First Nations peoples are critical to ensuring the gap in outcomes between First Nations and non-Indigenous peoples is closed. The identification of First Nations peoples is vital to enable the delivery of culturally safe and sensitive health care. Complete and accurate health data are essential for funding and evaluation of such initiatives. AIMS: To describe the processes used and accuracy of identification and documentation of First Nations mothers and babies during the period of the implementation of a culturally responsive caseload model of maternity care at three major metropolitan maternity services in Melbourne, Australia. MATERIALS AND METHODS: A cross-sectional study was conducted using administrative and clinical data. RESULTS: There was variation in when and how First Nations identification was asked and documented for mothers and babies. Errors included 14% of First Nations mothers not identified at the first booking appointment, 5% not identified until after the birth and 11% of First Nations babies not identified in the Victorian Perinatal Data Collection documentation. Changes to documentation and staff education were implemented to improve identification and reduce inaccuracies. CONCLUSIONS: To improve disparities in health outcomes, mainstream health services must respond to the needs of First Nations peoples, but improved care first requires accurate identification and documentation of First Nations peoples. Implementing and maintaining accuracy in collection and documentation of First Nations status is essential for health services to provide timely and appropriate care to First Nations people and to support and grow culturally appropriate and safe services.

"One of the most important subjects for a healthcare worker": Cross-sectional student evaluation of family violence best practice response curriculum.

Family violence can affect the health and well-being of victim-survivors. Nurses and other healthcare providers are well placed to respond to family violence, yet evidence shows that nurses have limited knowledge of family violence and students are unprepared for this work. The objective of this study was to evaluate a pilot of the subject Family Violence Best Practice Response for undergraduate nurses and other healthcare students at an Australian university. The study used a cross-sectional pre-posttest design. Survey instruments included a modified version of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) tool and the World Health Organization Curriculum evaluation tools. Sixty-four students enrolled in the pilot. Participants made significant improvements in their feelings of preparedness to complete family violence work and in their perceived knowledge across a range of clinical practices and knowledge domains. Qualitative data showed students enjoyed the subject and gained valuable knowledge of how to inquire and validate disclosures. Healthcare professionals should receive training and be ready and able to identify and sensitively respond to victim-survivors of family violence when they enter the workforce.

Perinatal outcomes of women with a disability who received pregnancy care through a specialised disability clinic in Melbourne, Australia.

BACKGROUND: In Australia, it is estimated that 9.5% of women of childbearing age have a disability; however, little is known about their perinatal outcomes. Disability status is not routinely recorded in perinatal datasets. AIMS: To compare the outcomes of women with a disability who received pregnancy care through a specialised disability clinic at the Royal Women's Hospital (the Women's) in Melbourne, Australia with hospital-wide perinatal outcome data. MATERIALS AND METHODS: Routinely collected perinatal data for women who received pregnancy care from the 'Women with Individual Needs' (WIN) clinic from 2014-2018 (N = 111) were analysed and then compared with routinely collected electronic hospital data obtained from all women who had given birth at the Women's in 2017 and 2018 (N = 15 024). RESULTS: Women who attended the WIN clinic were more likely to have a caesarean section birth (52% vs 32%; P < 0.001) and give birth preterm (17% vs 4%; P < 0.001) than those in the hospital-wide cohort. Their infants were more likely to be low birthweight (20% vs 9%; P < 0.001), require resuscitation (35% vs 11%; P < 0.001), be admitted to the Neonatal Intensive Special Care Unit (29% vs 13%; P < 0.001) and receive formula in hospital (54% vs 28%; P < 0.001) compared to infants in the other group. CONCLUSIONS: Routine maternity data collection should include identification of women with a disability to enable appropriate support and to allow further exploration of potential poorer outcomes on a larger sample, to help identify factors amenable to interventions that may improve outcomes.

Consideration for primary prevention implantable cardioverter defibrillators differ between specialities.

PURPOSE: Implantable cardioverter defibrillator (ICD) implantation rates remain variable despite established guideline recommendations. This study aims to assess whether being managed by a cardiologist has an impact on whether patients are considered for an ICD for primary prevention of sudden cardiac death. DESIGN/METHODS: Single-centre, retrospective, observational study of patients identified to have severe left ventricular systolic dysfunction (LVSD) on echocardiography (n = 129) between 1 and 30 June 2016 with cross-sectional assessment at 1 year. An assessment of ICD consideration at 1 year following the echocardiogram was documented, in addition to the specialty of the managing physician (group 1-electrophysiologist/heart failure specialist; group 2-all other cardiologists; group 3-non-cardiologist). RESULTS: 129/1173 (11%) transthoracic echocardiographies (s) were identified to have severe LVSD. 52 (40%), 37 (29%) and 40 (31%) were managed by group 1, group 2 and group 3, respectively. Mean age was 74.7 (±12.6) years with a predominance of male gender (70.5%). An ICD was not considered in 47.3%. Those managed by a cardiologist were more likely to be considered for an ICD than a non-cardiologist (63.9% vs 30.0%; OR 4.0, 95% CI 1.8 to 8.8, p = 0.001) with a greater survival at 1 year (89.9% vs 52.5%, OR 8.1 95% CI 3.2 to 20.4, p < 0.001). Group 1 were more likely to consider ICD than group 2 cardiologists (75.0% vs 45.9%; OR 3.5; 95% CI 1.4 to 8.7, p = 0.005). CONCLUSION: There is significant variation between cardiologists and non-cardiologists, as well as within different cardiology subspecialists, when considering the option of ICD therapy for primary prevention.

What do Pregnant Women Know About the Healthy Eating Guidelines for Pregnancy? A Web-Based Questionnaire.

Objectives This study explored nutrition knowledge of pregnant women, and how it correlated with participant characteristics, their main sources of information and changes to their diet since becoming pregnant. Methods Pregnant women residing in Australia accessing pregnancy forums on the internet were invited to complete a web-based questionnaire on general nutrition and pregnancy-specific nutrition guidelines. Results Of the 165 eligible questionnaire responses, 114 were complete and included in the analysis. Pregnancy nutrition knowledge was associated with education (r s = 0.21, p < 0.05) and income (r s = 0.21, p < 0.05). Only 2 % of pregnant women achieved nutrition knowledge scores over 80 %. Few women received nutrition advice during their pregnancy, of which most were advised by their doctor. Dietary changes adopted since becoming pregnant included consuming more fruit, vegetables, dairy and high fibre foods. Conclusions for Practice Pregnant women in this study had limited knowledge of the dietary guidelines for healthy eating during pregnancy. Furthermore, nutrition counselling in maternity care appears to be infrequent. One approach to optimising maternal diets and subsequently preventing adverse health outcomes is to enhance their knowledge of the pregnancy nutrition guidelines through the provision of nutritional counselling. Furthermore, research exploring the access and use of nutrition resources, and nutrition advice provided to pregnant women is recommended to understand how knowledge impacts on dietary behaviour.

Advanced diabetes credentials for the community pharmacist: A pilot study.

OBJECTIVES: This study sought to: (1) determine the percentage of community pharmacists in Indiana with advanced diabetes credentials; (2) identify the perceived benefits and barriers that pharmacists have toward obtaining advanced diabetes credentials; and (3) assess the intent and interest in pursuing advanced diabetes credentials in the future. METHODS: A cross-sectional statewide telephone survey of community pharmacists in Indiana was conducted from November 2014 to March 2015. Survey items were derived from a compilation of structured and unstructured questions that were of interest to the research team. Questions regarding demographics, current credentials held, and common diabetes-related counseling topics were asked to all respondents. The research team also sought to determine pharmacists' perceptions of the benefits and barriers to obtaining advanced diabetes credentials. The survey was divided into 3 sections: personal and professional demographics, current credentials, and perceptions of diabetes credentials. Respondents answered dichotomous, Likert-scale response, and open-ended questions. Six research assistants administered the survey. RESULTS: A total of 1024 community pharmacies were contacted, and 907 pharmacists responded, for an 88.5% response rate. Of the 907 participants, 9 pharmacists (<1%) held advanced diabetes credentials, and 6 others held advanced diabetes credentials that had expired. One-half (50%) of pharmacists agreed that advanced diabetes credentials were important for all community pharmacists, although 45% of all pharmacists surveyed did not think that advanced diabetes credentials were necessary for delivering patient care services. CONCLUSION: Despite the opportunity for community pharmacists to expand their role in advanced diabetes care, few have obtained advanced diabetes credentials, and available research has yet to articulate the barriers inhibiting the process. Results from this pilot survey will provide insight into the future dissemination of a nationwide survey to community pharmacists.

Comparing satisfaction and burnout between caseload and standard care midwives: findings from two cross-sectional surveys conducted in Victoria, Australia.

BACKGROUND: Caseload midwifery reduces childbirth interventions and increases women's satisfaction with care. It is therefore important to understand the impact of caseload midwifery on midwives working in and alongside the model. While some studies have reported higher satisfaction for caseload compared with standard care midwives, others have suggested a need to explore midwives' work-life balance as well as potential for stress and burnout. This study explored midwives' attitudes to their professional role, and also measured burnout in caseload midwives compared to standard care midwives at two sites in Victoria, Australia with newly introduced caseload midwifery models. METHODS: All midwives providing maternity care at the study sites were sent questionnaires at the commencement of the caseload midwifery model and two years later. Data items included the Midwifery Process Questionnaire (MPQ) to examine midwives' attitude to their professional role, the Copenhagen Burnout Inventory (CBI) to measure burnout, and questions about midwives' views of caseload work. Data were pooled for the two sites and comparisons made between caseload and standard care midwives. The MPQ and CBI data were summarised as individual and group means. RESULTS: Twenty caseload midwives (88%) and 130 standard care midwives (41%) responded at baseline and 22 caseload midwives (95%) and 133 standard care midwives (45%) at two years. Caseload and standard care midwives were initially similar across all measures except client-related burnout, which was lower for caseload midwives (12.3 vs 22.4, p = 0.02). After two years, compared to midwives in standard care, caseload midwives had higher mean scores in professional satisfaction (1.08 vs 0.76, p = 0.01), professional support (1.06 vs 0.11, p <0.01) and client interaction (1.4 vs 0.09, p <0.01) and lower scores for personal burnout (35.7 vs 47.7, p < 0.01), work-related burnout (27.3 vs 42.7, p <0.01), and client-related burnout (11.3 vs 21.4, p < 0.01). CONCLUSION: Caseload midwifery was associated with lower burnout scores and higher professional satisfaction. Further research should focus on understanding the key features of the caseload model that are related to these outcomes to help build a picture of what is required to ensure the long-term sustainability of the model.

Women's views and experiences of a new Midwifery Group Practice model in rural Australia.

BACKGROUND: Women in rural Australia often have limited maternity care options available, and in Victoria, like many Australian states, numerous small hospitals no longer offer birthing services. AIM: To evaluate women's views and experiences of maternity care at a local rural hospital that re-established birthing services with a Midwifery Group Practice (MGP) model of maternity care. METHODS: Women who booked into the new MGP model from May 2021 to June 2022 were invited to complete an anonymous online survey and participate in an optional additional semi-structured interview to explore their views and experiences. Descriptive statistics were used for quantitative data, and open-ended survey and interview responses were analysed using a general inductive approach. FINDINGS: Sixty-seven percent (44/66) of women completed the survey and five also completed an interview. Women were highly satisfied with the care they received. They felt respected, empowered, and had a sense of agency throughout their pregnancies, labour and birth, and post-birth. They reported low levels of anxiety during labour and birth, and felt that they coped physically and emotionally better than they anticipated. They felt well supported by midwives and highly valued the continuity of care within the MGP model. CONCLUSION: Women's voices play a critical role in informing maternity care provision, particularly for those in rural communities who may have limited access to care options. The findings support and expand on existing research regarding the value of midwifery continuity of care models, and can inform other rural maternity services in introducing similar models.

How are women with a disability identified in maternity services in Australia? A cross-sectional survey of maternity managers.

BACKGROUND: Women with a disability have poorer perinatal outcomes, but little is known about the prevalence of women with a disability accessing maternity services, how they are identified and what care and services are available. Estimates suggest that nine percent of women of childbearing age have a disability. AIM: To explore how public maternity services in Australia identify pregnant women with a disability, what (if any) routine disability identification questions are used, and to examine availability and adequacy of services for women. METHODS: Cross-sectional online survey of maternity managers in Australian public hospitals. FINDINGS: Thirty-six percent (70/193) of eligible hospitals responded including all states and territories. Overall, 71 % routinely asked women about disability status (usually as part of routine history taking), however there was wide variation in how this was asked. Most (63 %) did not have standardised documentation processes and two thirds (65 %) were unable to estimate the number of women with a disability seen at their hospital. Most (68 %) did not offer specialised services, with only 13 % having specialised training for staff in disability identification, documentation and referral pathways. Only a quarter of respondents felt that there were adequate services for women with a disability related to maternity care. CONCLUSION: This is the first study to explore disability identification in maternity services in Australia. How women were asked was highly varied and documentation not standardised. National guidelines on disability identification for women accessing maternity services should be developed and collection of disability identification data should be routine.

Optimising maternity care for a subsequent pregnancy after a psychologically traumatic birth: A scoping review.

BACKGROUND: Psychological birth trauma is recognised as a significant and ubiquitous sequelae from childbirth, with the incidence reported as up to 44%. In a subsequent pregnancy, women have reported a range of psychological distress symptoms from anxiety, panic attacks, depression, sleep difficulties and suicidal thoughts. AIM: To summarise evidence on optimising a positive pregnancy and birth experience for a subsequent pregnancy following a psychologically traumatic pregnancy and identify research gaps. METHODS: This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR check list. Six databases were searched using key words relating to psychological birth trauma and subsequent pregnancy. Utilising agreed criteria, relevant papers were identified, and data were extracted and synthesised. RESULTS: A total of 22 papers met the inclusion criteria for this review. All papers addressed different aspects of what was important to women in this cohort, summarised as women wanting to be at the centre of their care. Pathways of care were diverse ranging from free birth to elective caesarean. There was no systematic process for identifying a previously traumatic birth experience and no education to enable clinicians to understand the importance of this. CONCLUSION: For women who have experienced a previous psychologically traumatic birth, being at the centre of their care, in their subsequent pregnancy, is a priority. Embedding woman-centred pathways of care for women with this experience, as well as multidisciplinary education on the recognition and prevention of birth trauma, should be a research priority.

Exploring disability prevalence among childbearing women attending a tertiary maternity service in Melbourne, Australia using an audit and cross-sectional survey.

BACKGROUND: Although there is an estimated rate of 10% of women of childbearing age in Australia who have a disability, there is a lack of accurate prevalence data, with the true rate unknown. The timing and questions used to collect women's disability status in pregnancy vary, and there is limited knowledge on how women accessing maternity services in Australia would like to be asked about their disability status. OBJECTIVE: To explore the prevalence of women with a disability receiving maternity care using a direct and indirect disability identification question. Secondary aims were to explore how women would like to be asked about their disability status and to examine the difference between self-reported and clinician-documented disability status within medical records. RESEARCH DESIGN/SETTING: The study was conducted at a tertiary maternity hospital in Melbourne, Australia, and included two components. Component one used a cross-sectional survey with two different cohorts of women administered face-to-face on the postnatal ward (Cohort 1 - February 2019, Cohort 2 - December 2019). In Cohort 1, a specific disability identification question asked: 'Can you please tell me if you identify as someone who has a disability?'. In Cohort 2, an indirect disability identification question asked: 'Do you require additional assistance or support?'. Other questions explored women's views on disability identification. Component two consisted of an audit of the medical records to compare disability documentation in the medical records of the women who participated with women's disability self-identification status. RESULTS: 371/467 (79%) of eligible women that were approached participated in Cohort 1 and in Cohort 2, 295/346 (85%) of eligible women that were approached participated in the study. In Cohort 1, 5% (17/371) of women self-identified with having a disability. In Cohort 2 16% (46/295) of women reported needing additional assistance/support, however of these, only nine women viewed this as a disability. In Cohort 1, of the women who self-identified as having a disability, 82% had this recorded in their medical record. An additional 12% (43/354) of women in Cohort 1 who may have had a disability according to the Australian Bureau of Statistics classification, did not self-identify as having a disability. In Cohort 2, 37% (17/43) of women who self-identified as needing additional support did not have these needs documented in the medical record. Less than a quarter of women in both cohorts were asked about their disability status during their maternity care. Women with a disability or additional support needs suggested both direct and indirect ways of being asked about their disability status, and their responses were similar to women who did not self-identify with having a disability or additional support needs. CONCLUSIONS: Disability prevalence data is highly dependant on the wording of the disability identification question. It may be appropriate to ask about disability both indirectly, in terms of additional support needs, and directly, to enable disclosure for those who do identify with a disability. Disability questioning should be routine and standardised guidelines around disability identification should be developed to allow for tailored adjustments to care on an individual level.

Supporting the midwifery workforce: An evaluation of an undergraduate midwifery student employment model at a large tertiary maternity service in Victoria, Australia.

BACKGROUND: In 2020, in response to major maternity workforce challenges exacerbated by the COVID-19 pandemic, the Victorian Department of Health implemented a number of workforce maximisation strategies, one of which was employment of undergraduate midwifery students called 'Registered Undergraduate Student Of Midwifery' (RUSOM). AIM: To evaluate the RUSOM model implemented in a tertiary maternity service in Melbourne, Australia. METHODS: A cross-sectional online survey was distributed to all RUSOMs and midwives at the study site in August 2021. FINDINGS: Twenty of 26 RUSOMs (77%) and 110 of 338 permanent midwives (33%) responded. Both groups considered the model to be a positive workforce strategy that contributed to work readiness of students, and increased confidence and competence to practise. RUSOMS and midwives reported positives for the organisation including improving workload for midwives on the postnatal ward, enhancing quality of care and outcomes for women and babies, and the value of RUSOMs as team members. RUSOMs felt well supported, supervised and clinically and theoretically prepared. Both groups considered RUSOMs were underutilised, and that they could undertake additional duties, and both thought that the RUSOM model should continue. CONCLUSION: The model was highly valued by both RUSOMs and midwives. There was strong agreement that the model should continue and that the list of duties could be expanded. Given these findings, further research should explore the expansion and sustainability of RUSOMs in the maternity workforce.

Comparing the views of caseload midwives working with First Nations families in an all-risk, culturally responsive model with midwives working in standard caseload models, using a cross-sectional survey design.

PROBLEM: Little is known about midwives' views and wellbeing when working in an all-risk caseload model. BACKGROUND: Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby. AIM: Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services. METHODS: A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI). FINDINGS: 35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups. DISCUSSION AND CONCLUSION: Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.

Evaluating the clinical effectiveness of the NHS Health Check programme: a prospective analysis in the Genetics and Vascular Health Check (GENVASC) study.

OBJECTIVE: The aim of the study was to assess the clinical effectiveness of the national cardiovascular disease (CVD) prevention programme-National Health Service Health Check (NHSHC) in reduction of CVD risk. DESIGN: Prospective cohort study. SETTING: 147 primary care practices in Leicestershire and Northamptonshire in England, UK. PARTICIPANTS: 27 888 individuals undergoing NHSHC with a minimum of 18 months of follow-up data. OUTCOME MEASURES: The primary outcomes were NHSHC attributed detection of CVD risk factors, prescription of medications, changes in values of individual risk factors and frequency of follow-up. RESULTS: At recruitment, 18% of participants had high CVD risk (10%-20% 10-year risk) and 4% very high CVD risk (>20% 10-year risk). New diagnoses or hypertension (HTN) was made in 2.3% participants, hypercholesterolaemia in 0.25% and diabetes mellitus in 0.9%. New prescription of stains and antihypertensive medications was observed in 5.4% and 5.4% of participants, respectively. Total cholesterol was decreased on average by 0.38 mmol/L (95% CI -0.34 to -0.41) and 1.71 mmol/L (-1.48 to -1.94) in patients with initial cholesterol >5 mmol/L and >7.5 mmol/L, respectively. Systolic blood pressure was decreased on average by 2.9 mm Hg (-2.3 to -3.7), 15.7 mm Hg (-14.1 to -17.5) and 33.4 mm Hg (-29.4 to -37.7), in patients with grade 1, 2 and 3 HTN, respectively. About one out of three patients with increased CVD risk had no record of follow-up or treatment. CONCLUSIONS: Majority of patients identified with increased CVD risk through the NHSHC were followed up and received effective clinical interventions. However, one-third of high CVD risk patients had no follow-up and therefore did not receive any treatment. Our study highlights areas of focus which could improve the effectiveness of the programme. TRIAL REGISTRATION NUMBER: NCT04417387.

Managing projected midwifery workforce deficits through collaborative partnerships.

To address workforce shortages, the Australian Government funded additional nursing and midwifery places in 2009 pre-registration courses. An existing deficit in midwifery clinical placements, combined with the need to secure additional clinical placements, contributed to a serious shortfall. In response, a unique collaboration between Midwifery Academics of Victoria (MIDAC), rural and metropolitan maternity managers (RMM and MMM) groups and Department of Health (DOH) Victoria was generated, in order to overcome difficulties experienced by maternity services in meeting the increased need. This group identified the large number of different clinical assessment tools required to be being completed by midwives supervising students as problematic. It was agreed that the development of a Common Assessment Tool (CAT) for use in clinical assessment across all pre-registration midwifery courses in Victoria had the potential to reduce workload associated with student assessments and, in doing so, release additional placements within each service. The CAT was developed in 2009 and implemented in 2010. The unique collaboration involved in the development of the CAT is a blueprint for future projects. The collaboration on this project provided a range of benefits and challenges, as well as unique opportunities for further collaborations involving industry, government, regulators and the tertiary sector.

How and when doula support increases confidence in women experiencing socioeconomic adversity: Findings from a realist evaluation of an Australian volunteer doula program.

How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity-when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman's confidence via two possible pathways-by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula's recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence.

Matching of woman and doula, and the generation of trust in an Australian volunteer doula program: Findings from a realist evaluation.

How women are cared for while pregnant and having a new baby can have profound and lasting effects on their health and well-being. While mainstream maternity care systems aspire to provide care that is woman-centred, women with fewest social and economic resources often have reduced access. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when and why these programs work. A realist evaluation of an Australian volunteer doula program provided for women experiencing socioeconomic adversity explored these questions. The program provides free non-medical, social, emotional, and practical support by trained doulas during pregnancy, birth and new parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that the cultural matching of woman (client) and doula led to best outcomes. This was tested in realist interviews with women and focus groups with doulas, in January-February 2020. Seven English speaking, and six Arabic speaking clients were interviewed. Two focus groups were conducted with a total of eight doulas from diverse cultural and professional backgrounds. Data were analysed in NVivo. The study found cultural matching to be valued by some but not all women, and only when the doula was also genuinely interested, kind, timely and reliable. These approaches (with or without cultural matching) generate trust between the doula and woman. Trust theory, reflexivity theory and social relations theory supported explanatory understanding of the causal contribution of a doula knowing what it takes to build trust, to a woman deciding to trust her doula.