Dr Liz Newnham

Introduction: Contemporary ethical issues in the maternity system are nuanced, complex and layered. Medicalisation and the reported rise in incidence of mistreatment and birth trauma, has been described as unethical. Some authors suggest bioethical principles are limited in terms of guiding everyday care of pregnancy and birth. There is currently no known published research which explores what birthing people say is ethical. Aims: This study sought to explore women's experience of maternity care from an ethical perspective. Method: A Feminist Participatory Action Research (FPAR) was conducted over three years, in two phases. A Community Action Research Group (CARG) was formed of nine participants, and data were captured from five focus groups. A further ten participants were recruited for individual in-depth interviews, the data corpus was combined, and thematic analysis was applied. All 19 participants had experienced a midwifery model of care in Western Australia. Results: A unique ethical perspective was described by the participants. The central theme: ¿Radical desires: Individuals values and context¿ placed the woman at the centre of the care, in determining what is ethical. Two categories captured the care experienced: Woman-centred ethics or Authoritarian ethics. A conceptual model Woman-centred ethics is offered to enhance everyday ethical midwifery care. Discussion: The participants in this study perceived care as either ethical or unethical based on the quality of the relationship, the knowledge that was shared and the manner of the care given. The Woman-centred ethics model may be a starting point for moving the field forward in ethical discussion.

Background: Midwifery curricula in Australia incorporate ¿Continuity of care experiences¿ (CoCE) as an educational strategy based on an assumption that midwifery students will learn skills and knowledge about woman-centred care that they may not learn in the typical fragmented care system. However, exactly what skills and knowledge they are expected to ¿learn¿ and how these can be assessed have never been specifically identified. Aim: To explore midwifery students¿ continuity of care learning experiences within pre-registration midwifery education. Methods: Focus groups were conducted with first, second and third year Bachelor of Midwifery students (n = 12), who were undertaking CoCE in rural and regional tertiary hospitals in NSW, Australia. Findings: The overarching theme, ¿Learning through relationships¿, was made up of three interrelated themes: Meeting women and making connections, Being known, and Understanding holistic care. Discussion: The findings from this study contribute to understanding the educational effects of CoCE. The CoCE relationship provided safety and freedom to learn which was seen as foundational for midwifery students¿ vision of their future practice and can be seen as a self-determined transformational approach to learning. Conclusion: This study adds insight into midwifery students¿ experience of CoCE, and demonstrates that transformative learning occurs through developing a relationship with both the woman and the midwife. For midwifery to develop as a profession and maintain its focus on woman-centredness, it is important that this aspect of midwifery education remains embedded within midwifery program philosophies and learning outcomes.

Objectives: To develop and test a tool to measure Bachelor of Nursing students¿ perceptions towards respectful maternity care in Nepal, a lower-middle income country. Design: A cross-sectional design was used. Phases of tool development included item generation, expert review for content validity testing, and psychometric testing. The draft tool had 42 items on a 5-point Likert response scale of 1 = strongly disagree to 5 = strongly agree. Psychometric testing included dimensionality, internal consistency, and test-retest reliability. A t-test assessed mean score differences between students who had witnessed or not witnessed disrespect and abuse. Settings: Two medical colleges in Chitwan, Nepal Participants: Undergraduate Bachelor of Nursing students (n = 171) undertaking their midwifery clinical practicum were invited to complete the online survey. Findings: Principal component analysis generated three factors: Respectful Care, Safety and Comfort, and Supportive Care and explained 37.44% of the variance. The 18-item tool demonstrated good internal reliability (Cronbach's alpha of 0.81). The mean total scale score was 71.23 (SD 7.47, range 52-88 out of 90). Pearson's correlation coefficient confirmed test-retest reliability at one week (r = 0.91, p <0.001). The magnitude of difference in mean scores between those who had witnessed or not witnessed disrespectful and abusive care was very small (¿2 = 0.04). Key conclusion: The new Student Perceptions of Respectful Maternity Care tool is the first valid and reliable measure of students¿ perceptions of respectful maternity care. Validation of the newly developed tool in other low- and middle-income countries is recommended. Implications for practice: Measuring students¿ perceptions provides information to educators on how best to enhance students¿ understanding and provision of respectful care to women.

Aim: This systematic review critiqued the impact of educational interventions for midwives, nurses, or midwifery/nursing students to enhance respectful maternity care. Background: Treating women with respect during maternity care has gained considerable global attention. Although research has focused on raising awareness about respectful care among health care professionals, the effectiveness of educational interventions remains uncertain. Methods: A mixed-methods systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This review used a convergent segregated approach, and methodology recommended by Joanna Briggs Institute (JBI) mixed-methods systematic reviews, to synthesise and integrate research findings. Multiple databases were searched. JBI critical appraisal checklists for quasi-experimental studies, cross-sectional, and qualitative studies, as well as a mixed-methods appraisal tool were used. Findings: Nine educational interventions studies met the inclusion criteria, and most were conducted in Africa. Quantitative evidence supported the effectiveness of interventions to improve knowledge/perceptions of midwives and/or nurses regarding respectful maternity care, and woman-provider communication, and reduce women's experience of disrespect and abuse. However, variation in content, intervention delivery mode, duration, timing of pre and post-test, evaluation methods, and difficulty distilling findings from multi-pronged interventions hindered robust conclusions. Only one study used a valid and reliable tool to measure women's experience of respectful care. Qualitative findings suggest continuous education rather than one-off interventions and inclusion of other health care providers as well as managerial staff working in maternity care would help promote respectful care. Conclusion: There is low level evidence that educational interventions can improve midwives¿, nurses¿, and students¿ knowledge and attitudes towards RMC. Outcomes of education and training need to be monitored regularly with valid and reliable tools. There is a need for respectful maternity care education interventions in high as well as middle and low-income countries.

Background. Midwifery is an internationally mobile profession, but there has been relatively little consideration given regarding the integration of internationally qualified midwives (IQMs), specifically from non-English speaking backgrounds (NESB), when practising midwifery in Australia and other developed nations. Aim. The initial aim of this literature review was to explore literature relating to the experiences of IQMs from NESB working in Australia and other developed nations. Due to a lack of publications in this area, the aim was expanded to include research about IQMs and internationally qualified nurses IQNs from NESB and English speaking backgrounds (ESB). Methods. Based on Cooper¿s five stages of research review (1989), a comprehensive search of 11 electronic databases was conducted. The databases included Medline, CINAHL and Scopus as well as grey literature. Search terms included ¿internationally qualified midwives and nurses¿, ¿overseas educated¿ and ¿acculturation¿. Mesh terms were combined with free-text words. Findings. A total of 27 studies met the inclusion criteria. The findings indicate that challenges co-exist for both IQMs and IQNs while working in a new foreign healthcare system. Four common challenges were extracted from the included literature: communication challenges, cultural displacement, variations in midwifery and nursing practices, and bullying and discrimination. Conclusion. Migration to new countries with diversity in language and cultural practices can cause a sense of vulnerability for IQMs and IQNs. These are increased with differences in midwifery and nursing practices and the highlighted risk of bullying.

Background. Increasing intervention in birth continues to be a cause for concern and epidural analgesia is an ever more common intervention. A major influence on rising intervention rates is the complex relationship society has with technology. Influenced by various political and cultural narratives, there has been a tendency to view technological advance as both neutral and superior in the human quest for progress. Aim. In this paper, the authors trace the dialectical relationship between culture and technology in order to investigate the way epidural analgesia is portrayed in the biomedical literature. Method. A purposeful literature search was conducted, with databases including CINAHL, MEDLINE, Scopus, Google Scholar, Academic Search Premier and thesis repositories. Relevant literature was identified and analysed using the analytic framework of critical discourse analysis and drawing on critical medical anthropology and Foucault's discourse analysis. Findings. The biomedical literature on epidural analgesia concerned itself with particular outcomes, such as increases in CS and instrumental birth rates, and yet maintained its narrative of epidural as 'safe and effective'. Implications. By exposing the contextual nature of knowledge, another standpoint is offered from which evidence and practice can be reviewed. This critical literature review provides an alternate reading of epidural text and challenges some of the assumptions made about epidural analgesia, and the practices that stem from these beliefs.

In this article, we discuss the use of critical medical anthropology (CMA) as a theoretical framework for research in the maternity care setting. With reference to the doctoral research of the first author, we argue for the relevance of using CMA for research into the maternity care setting, particularly as it relates to midwifery. We then give an overview of an existing analytic model within CMA that we adapted for looking specifically at childbirth practices and which was then used in both analyzing the data and structuring the thesis. There is often no clear guide to the analysis or writing up of data in ethnographic research; we therefore offer this Critical analytic model of childbirth practices for other researchers conducting ethnographic research into childbirth or maternity care.