Professor Maralyn Foureur

The chapter begins by exploring the concepts of 'salutogenesis' and 'pathogenesis' in order to reveal the way society's view of childbirth has resulted in a particular set of familiar features in the architecture and design of birth units. Salutogenic design for birth requires much more than providing a restful 'ambiance' in the birth space or even simply adding nature views. The infant resuscitaire located beside the cardio-toco-graphic machine is a constant reminder that in this setting, birth is regarded as a situation of high risk for the baby who may need urgent resuscitative measures at birth. The concept of the "Fear Cascade" describes neurohormonal responses women may have to birth spaces that may be overtly or covertly considered to be unsafe or fear-inducing. Exploring how the built environment facilitates or inhibits the supporters' role provides additional insights into the experiences of women during childbirth.

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.

Background: Asthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4¿6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia. Aim: To explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations. Method: Pregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019. Results: The survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving ¿usual¿ care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information. Conclusions: Overall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.

Background: Supporting women to achieve healthy gestational weight gain is a global health challenge. Inadequate and excessive gestational weight gains are associated with short and long-term adverse maternal and infant health outcomes. Qualitative studies suggest that symptoms of pregnancy, health professional attitudes, lack of guidance, personal knowledge and beliefs, lack of support, weight stigma, and lack of time and money, are barriers to achieving healthy weight gain. Less is known about women's perceptions and experience of gestational weight gain within normal body mass index categories with even less known about the experience of women motivated to participate in pregnancy weight management intervention trials. Aim: To describe the experience and perspectives of women participating in an Australian weight management pilot randomised controlled trial. Methods: Five women from regional New South Wales enrolled in the Eating 4 Two trial, participated in semi - structured interviews during the post-natal period. A qualitative descriptive methodology and inductive thematic analysis was applied. Findings: Two main themes emerged: 1) Addressing weight gain in pregnancy; and 2) Pregnancy weight the balancing act. Women identified weight gain as an important topic, the need for improvements within maternity services, responsive feedback and realistic support strategies. Women identified pregnancy symptoms, occurring during early and late pregnancy as barriers to achieving healthy weight gain. Conclusion: Further investigation into the effects of pregnancy symptoms on eating and physical activity patterns across pregnancy is warranted. Both qualitative and quantitative research is needed to monitor the translation of guideline recommendations into clinical practice.

Background: Changing people¿s behaviour by giving advice and instruction, as traditionally provided in healthcare consultations, is usually ineffective. Healthy Conversation Skills (HCS) training enhances health professionals¿ communication skills and ability to empower and motivate people in health behaviour change. Guided by the Theoretical Domains Framework (TDF), this¿study examined the impact of HCS training on health professional barriers to conducting behaviour change conversations in both clinical and non-clinical settings. Secondary aims were to i) identify health professionals¿ barriers to having behaviour change conversations, and explore the ii) effect of HCS training on health professionals¿ competence and attitudes to adopting HCS, iii) feasibility, acceptability and appropriateness of using HCS in their clinical and non-clinical roles, and iv) acceptability and quality of HCS training. Methods: HCS training was conducted in October-November 2019 and February 2020. Pre-training (T1), post-training (T2) and follow-up (T3; 6-10 weeks post-training) surveys collected data on demographics and changes in competence, confidence, importance and usefulness (10-point Likert scale, where 10 = highest score) of conducting behaviour change conversations. Validated items assessing barriers to having these conversations were based on eight TDF domains. Post-training acceptability and quality of training was assessed. Data were summarised using descriptive statistics, and differences between TDF domain scores at the specific time points were analysed using Wilcoxon matched-pairs signed-rank tests. Results: Sixty-four participants consented to complete surveys (97% women; 16% identified as Aboriginal), with 37 employed in clinical settings and 27 in non-clinical settings. The training improved scores for the TDF domains of skills (T1: median (interquartile range) = 4.7(3.3-5.3); T3 = 5.7(5.3-6.0), p < 0.01), belief about capabilities (T1 = 4.7(3.3-6.0); T3 = 5.7(5.0-6.0), p <¿0.01), and goals (T1 = 4.3(3.7-5.0); T3 = 4.7(4.3-5.3), p < 0.01) at follow-up. Competence in using ¿open discovery questions¿ increased post-training (T1 = 25% of responses; T2 = 96% of responses; T3 = 87% of responses, p < 0.001), as did participants¿ confidence for having behaviour change conversations (T1 = 6.0(4.7-7.6); T2 = 8.1(7.1-8.8), p <¿0.001), including an increased confidence in having behaviour change conversations with Aboriginal clients (T1 = 5.0(2.7-6.3); T2 = 7.6(6.4-8.3), p <¿0.001). Conclusions: Provision of additional support strategies to address intentions; memory, attention and decision processes; and behavioural regulation may enhance adoption and maintenance of HCS in routine practice. Wider implementation of HCS training could be an effective strategy to building capacity and support health professionals to use a person-centred, opportunistic approach to health behaviour change.

Problem: Studies investigating the direct and indirect relationships between psychosocial factors (i.e. attitudes, beliefs and values), health related behaviour (diet and physical activity) and gestational weight gain are increasing. To date heterogeneity of psychosocial measurement tools has limited research progress in this area, preventing measurement of effects by meta-analysis techniques. Aim: To conduct a revalidation analysis of a Weight Related Behaviours Questionnaire, originally developed by Kendall, Olson and Frangelico within the United States of America and assess its performance for use within the Australian context. Methods: A revalidation study using Exploratory Factor Analysis was undertaken to assess the factor structure and internal consistency of the six psychosocial scales of the Weight Related Behaviours Questionnaire, within the Woman and Their Children's Health (WATCH), pregnancy cohort. The questionnaire was self-completed between 18 ¿ 20 weeks gestation. Psychosocial factors included; Weight locus of control; Self-efficacy; Attitudes towards weight gain; Body image, Feelings about the motherhood role; and Career orientation. Findings: Weight locus of control, Self-efficacy and Body image, retained the same factor structure as the original analysis. The remaining psychosocial factors observed a different factor structure in terms of loadings or number of factors. Deleted items modelling suggests the questionnaire could be strengthened and shortened. Conclusion: Weight Locus of control, Self-efficacy and Body image were observed as consistent, valid and reliable psychosocial measures for use within the Australian context. Further research is needed to confirm the model and investigate the potential for combining these scales into a shorter psychosocial measurement tool.

Background: Developmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention. Aims and objectives: The objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care. Design: This involves a cross-sectional survey design. Methods: An online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys. Results: Differences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2¿1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9¿6.2] and [OR: 2.1, 95% CI: 0.6¿7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3¿9.9) than metropolitan respondents. Conclusion: The application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

Background: Unexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section. Aim: To map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation. Methods: A custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 ¿evidence-based¿ statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses. Findings: Total 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications ¿valid¿ compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age=40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section. Discussion: Both inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines. Conclusion: Greater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.

Infants hospitalised in neonatal intensive care units require interventions for lifesaving care and to meet basic human needs. Evidence that stress influences neurodevelopment suggests the effects of caregiving in the neonatal intensive care unit (NICU) warrant further investigation to assess links with infant developmental outcomes. This review explores the effects of nurse-delivered caregiving in the NICU on infant physiological and behavioural responses, and longer-term developmental outcomes (behaviour and temperament). CINHAL, MEDLINE and PsychINFO were systematically searched for studies in peer-reviewed journals related to nurse-delivered caregiving and developmental outcomes. Synthesis of the literature identified altered physiological and behavioural responses as immediate effects of caregiving in neonatal settings, and non-optimal developmental outcomes. Results indicate that caregiving is not innocuous. Yet, little is known about nurses¿ perceptions of the effects of caregiving. Identifying the care components that influence development is essential to minimise the potentially adverse impact of the NICU experience on infants and families.

Objective: In many high-income countries, approximately half of all births are now planned regarding timing, either by elective Caesarean Section (CS) or induction of labour (IOL). To what degree this is explained by women's birth beliefs and preferences, and in turn, factors such as parity and ethnicity that may influence them, is contentious. Within a broader study on Timing of Birth by planned CS or IOL, we aimed to explore the association between demographic and pregnancy factors, with women's birth beliefs and experiences of planned birth decision-making in late pregnancy. Design: Survey study of women's birth beliefs and experiences of planned birth decision-making. Both univariate analysis and ordinal regression modelling was performed to examine the influence of; parity; cultural background; continuity of pregnancy care; CS or IOL; and whether CS was ¿recommended¿ or ¿requested¿, on women's stated birth beliefs and decision-making experience. Setting: 8 Sydney hospitals Participants: Women planned to have an IOL or CS between November 2018-July 2019. Measurement: The survey included four statements regarding birth beliefs and ten statements about experiences of decision-making on a 5-item Likert scale, as well as questions about demographic and pregnancy factors that might influence these beliefs. Findings: Of 340 included surveys, 56% regarded IOL and 44% CS. Women indicated strong belief both that they should be supported to make decisions about their birth and that their doctor/midwife knows what is best for them (over 90% agreement for both). Regarding decision-making, over 90% also agreed they had trust in the person providing information, understood it, and had sufficient time for both questions and decision-making. However only 58% were provided written information, 19% felt they ¿didn't really have a choice¿, and 9% felt pressure to make a decision. On both univariate and multivariate analysis, women having CS (versus IOL) expressed more positive views of their experience and involvement in decision-making, as did women experiencing a pregnancy continuity-of-care model. Women identifying as from a specific cultural or ethnic background expressed more negative experiences. On modelling, the studied factors accounted for only a small proportion of the variation in responses (3¿19%). Conclusions: Continuity of pregnancy care was associated with positive decision-making experiences and cultural background with more negative experiences. Women whose planned birth was IOL versus CS also reported more negative decision-making experiences. Implications for practice: Attention to improving quality of information provision, including written information, to women having IOL and women of diverse background, is recommended to improve women's experiences of planned birth decision-making.

Background: A new wireless and beltless monitoring device utilising fetal and maternal electrocardiography (ECG) and uterine electromyography, known as ¿non-invasive fetal ECG¿ (NIFECG) was registered for clinical use in Australia in 2018. The safety and reliability of NIFECG has been demonstrated in controlled settings for short periods during labour. As far as we are aware, at the time our study commenced, this was globally the first trial of such a device in an authentic clinical setting for the entire duration of a woman¿s labour. Methods: This study aimed to assess the feasibility of using NIFECG fetal monitoring for women undergoing continuous electronic fetal monitoring during labour and birth. Women were eligible to participate in the study if they were at 36 weeks gestation or greater with a singleton pregnancy, planning to give birth vaginally and with obstetric indications as per local protocol (NSW Health Fetal Heart Rate Monitoring Guideline GL2018_025. 2018) for continuous intrapartum fetal monitoring. Written informed consent was received from participating women in antenatal clinic prior to the onset of labour. This single site clinical feasibility study took place between January and July 2020 at the Royal Hospital for Women in Sydney, Australia. Quantitative and qualitative data were collected to inform the analysis of results using the NASSS (Non-adoption, Abandonment, Scale up, Spread and Sustainability) framework, a validated tool for analysing the implementation of new health technologies into clinical settings. Results: Women responded positively about the comfort and freedom of movement afforded by the NIFECG. Midwives reported that when no loss of contact occurred, the device enabled them to focus less on the technology and more on supporting women¿s physical and emotional needs during labour. Midwives and obstetricians noticed the benefits for women but expressed a need for greater certainty about the reliability of the signal. Conclusion: The NIFECG device enables freedom of movement and positioning for labouring women and was well received by women and the majority of clinicians. Whilst measurement of the uterine activity was reliable, there was uncertainty for clinicians in relation to loss of contact of the fetal heart rate. If this can be ameliorated the device shows potential to be used as routinely as cardiotocography (CTG) for fetal monitoring. This is the first time the NASSS framework has been used to synthesise the implementation needs of a health technology in the care of women during labour and birth. Our findings contribute new knowledge about the determinants for implementation of a complex technology in a maternity care setting. Trial registration: The Universal Trial Number is reU1111-1228-9845 and the Australian and New Zealand Clinical Trial Registration Number is 12619000293167p. Trial registration occurred on the 20 February, 2019. The trial protocol may be viewed at http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377027.

Background: Rates of induction of labour have been increasing globally to up to one in three pregnancies in many high-income countries. Although guidelines around induction, and strength of the underlying evidence, vary considerably by indication, shared decision-making is increasingly recognised as key. The aim of this study was to identify women's mode of birth preferences and experiences of shared decision-making for induction of labour. Method: An antenatal survey of women booked for an induction at eight Sydney hospitals was conducted. A bespoke questionnaire was created assessing women's demographics, indication for induction, pregnancy model of care, initial birth preferences, and their experience of the decision-making process. Results: Of 189 survey respondents (58% nulliparous), major reported reasons for induction included prolonged pregnancy (38%), diabetes (25%), and suspected fetal growth restriction (8%). Most respondents (72%) had hoped to labour spontaneously. Major findings included 19% of women not feeling like they had a choice about induction of labour, 26% not feeling adequately informed (or uncertain if informed), 17% not being given alternatives, and 30% not receiving any written information on induction of labour. Qualitative responses highlight a desire of women to be more actively involved in decision-making. Conclusion: A substantial minority of women did not feel adequately informed or prepared, and indicated they were not given alternatives to induction. Suggested improvements include for face-to-face discussions to be supplemented with written information, and for shared decision-making interventions, such as the introduction of decision aids and training, to be implemented and evaluated.

Background: Midwifery is based on the philosophy of woman-centred care. The continuity of care experience in pre-registration education programs exemplifies this philosophy. Wide variation in how education providers implement ¿Continuity of Care Experiences¿ into their programs of study can challenge this valuable learning opportunity. Aim: To provide a comprehensive analysis of the governance and empirical evidence of knowledge, practice and enablers to support continuity of care experiences within pre-registration midwifery education. Method: A scoping review of research, policy and professional documents pertaining to the continuity of care experience in pre-registration education programs was conducted with 46 articles meeting the inclusion criteria. Findings: Several factors were identified that support the implementation, facilitation and evaluation of the continuity of care experience within pre-registration midwifery education. These include: a woman-centred model of maternity care; enabling midwifery students and women to develop ¿relational continuity¿; tripartite support models; optimising the sequencing of these experiences within the program and, woman-led evaluations of student performance. There was little consensus regarding the pedagogical intent and, therefore, an inability to clearly define and measure the learning outcomes of the continuity of care experience. Conclusion: In countries where the predominant model of maternity care is fragmented and not woman-centred, further research is required to understand the pedagogical intent of the continuity of care experience.

Objective: Freedom of movement and choice of positioning in labour and birth is known to enhance physiological processes and positive experiences for women during childbirth. Continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies, such as wireless CTG, have been marketed for clinical use in most high resource settings since 2003 but there is a paucity of midwifery literature about its clinical use. The aim of this survey was to determine how often, and for whom, wireless and beltless technologies are being used in maternity settings across Australia and New Zealand and to identify any barriers to their uptake. Design: A survey tool developed by Watson et al. (2018) for use in the United Kingdom was adapted for the Australian/New Zealand context. One Maternity Unit Manager or key midwifery clinician from each of 208 public and private hospitals across Australia and New Zealand was invited by email to participate in an online survey between October 2019 and January 2020. Descriptive statistics were used to describe the characteristics of the facilities and the frequency of availability of the monitors. Free text responses were thematically analysed. Findings: The survey received a high (71%) response rate from a range of public and private hospitals in urban and rural settings. Women's freedom of movement and sense of choice and control in labour were seen by most respondents to be positively influenced by wireless monitoring technology. Most facilities reported having at least one wireless or beltless foetal monitor available, however, results suggest that many women consenting to continuous monitoring still do not have access to technology that enables freedom of movement. Keyconclusions: Further research is required to explore the barriers and facilitators to enabling freedom of movement and positioning to all women in childbirth, including those women with complex pregnancies who may consent to continuous foetal monitoring.

Background: There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making. Method: A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers. Findings: In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39 weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines. Conclusion: The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.

Background: Inadequate or excessive gestational weight gain is associated with both short and long-term adverse maternal and infant health outcomes. The practice of routine maternal weight monitoring has been suggested as an effective health promotion intervention, both as a screening tool for adverse maternal and infant outcomes and as a weight management strategy for addressing gestational weight gain. Discussion: The effectiveness of routine maternal weighing as part of maternity care has been debated for more than 30 years. The National Health and Medical Research Council of Australia have recently revised their pregnancy care clinical practice guidelines recommending maternal weight monitoring (clinician and/or self-weighing) be reintroduced into clinical practice. This paper presents a timely discussion of the topic that will contribute new insights to the debate. Conclusion: Weight gain in pregnancy is complex. Evaluation of the translation, implementation, acceptability and uptake of the newly revised guidelines is warranted, given that evidence on the practice remains inconclusive. Future research exploring social ecological interventions to assist pregnant women achieve optimal gestational weight gains are suggested to expand the evidence base.

Background: There is widespread and some unexplained variation in induction of labour rates between hospitals. Some practice variation may stem from variability in clinical guidelines. This review aimed to identify to what extent induction of labour guidelines provide consistent recommendations in relation to reasons for, and timing of, induction of labour and ascertain whether inconsistencies can be explained by variability guideline quality. Method: We conducted a systematic search of national and international English-language guidelines published between 2008 and 2018. General induction of labour guidelines and condition-specific guidelines containing induction of labour recommendations were searched. Guidelines were reviewed and extracted independently by two reviewers. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II Instrument. Findings: Forty nine guidelines of varying quality were included. Indications where guidelines had mostly consistent advice included prolonged pregnancy (induction between 41 and 42 weeks), preterm premature rupture of membranes, and term preeclampsia (induction when preeclampsia diagnosed =37 weeks). Guidelines were also consistent in agreeing on decreased fetal movements and oligohydramnios as valid indications for induction, although timing recommendations were absent or inconsistent. Common indications where there was little consensus on validity and/or timing of induction included gestational diabetes, fetal macrosomia, elevated maternal body mass index, and twin pregnancy. Conclusion: Substantial variation in clinical practice guidelines for indications for induction exists. As guidelines rated of similar quality presented conflicting recommendations, guideline variability was not explained by guideline quality. Guideline variability may partly account for unexplained variation in induction of labour rates.

Background: Women want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings. Aim: The aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales. Methods: A micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy. Findings: The median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings. Conclusion: In this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.

Background: The use of fractional exhaled nitric oxide (FeNO)-based asthma management during pregnancy can significantly reduce asthma exacerbations in non-smoking pregnant women. The feasibility of implementing this strategy into antenatal care has not been explored. Aims: To examine the feasibility of implementing FeNO-based asthma management into antenatal clinics in New South Wales (NSW) Australia. Materials and Methods: Semi-structured face-to-face interviews with video elicitation were conducted with healthcare professionals (HCPs) providing antenatal care in one of two hospital-based antenatal clinics in NSW, Australia. The video shown demonstrated the use of the FeNO instrument and other aspects of the management strategy, in antenatal care. Interviews were recorded, transcribed and analysed using qualitative content analysis. Results: A total of 20 interviews were conducted with 15 midwives, four obstetricians, and one general practitioner. Two main themes and ten sub-themes arose: Getting a number (sub-themes: engaging, technically easy, objective, predictive, reassuring); and Resourcing (sub-themes: time and timing, systems, staff, education and cost). Comments included: ¿It's easy, fast and effective¿ and ¿the main barrier is time¿. All HCPs felt capable of facilitating the FeNO-based management strategy, with appropriate education, and were willing to undertake this strategy, saying: ¿¿it would be perfectly acceptable for a midwife or doctor to do it¿; also, ¿they don't necessarily need to see a physician, it's something that midwives would take on generally¿¿. Conclusion: Participants in this study considered FeNO-based asthma management for pregnant women to be a feasible addition to antenatal care following appropriate provision of resources and education.

Background: Asthma affects approximately 12.7% of pregnant women in Australia. Increased maternal and infant morbidity is closely associated with poorly controlled asthma during pregnancy. Midwives are well placed to provide antenatal asthma management but data on current asthma management during pregnancy is not available, nor is the use of guidelines for clinical practice by this health professional group. Aim: To explore self-reported antenatal asthma management provided by midwives across Australia and how this reflects guideline recommendations. Method: An online survey was developed and distributed throughout Australia via the Australian College of Midwives, social media and healthcare facilities. Results: Responses from 371 midwives were obtained. Ten percent of midwives rated their knowledge as ¿good¿ and 1% as ¿very good¿, with 39% ¿poor¿ or ¿very poor¿. Being ¿somewhat¿ or ¿not at all¿ confident to provide antenatal asthma management was noted by 87% of midwives. Clinical guidelines were referred to by 50% of midwives and 40% stated that their main role was to refer women to other healthcare professionals. Only 54% reported that a clear referral pathway existed. Most respondents (>90%) recognised key recommendations for asthma management such as smoking cessation, appropriate vaccinations, and the continuation of prescribed asthma medications. Conclusion: Although midwives appear aware of key clinical recommendations for optimal antenatal asthma management, low referral to clinical practice guidelines and lack of knowledge and confidence was evident. Further research is required to determine what care pregnant women with asthma are actually receiving and identify strategies to improve antenatal asthma management by midwives.

Nurses and midwives of Australia now is the time for change! As powerfully placed, Indigenous and non-Indigenous nursing and midwifery professionals, together we can ensure an effective and robust Indigenous curriculum in our nursing and midwifery schools of education. Today, Australia finds itself in a shifting tide of social change, where the voices for better and safer health care ring out loud. Voices for justice, equity and equality reverberate across our cities, our streets, homes, and institutions of learning. It is a call for new songlines of reform. The need to embed meaningful Indigenous health curricula is stronger now than it ever was for Australian nursing and midwifery. It is essential that nursing and midwifery leadership continue to build an authentic collaborative environment for Indigenous curriculum development. Bipartisan alliance is imperative for all academic staff to be confident in their teaching and learning experiences with Indigenous health syllabus. This paper is a call out. Now is the time for Indigenous and non-Indigenous nurses and midwives to make a stand together, for justice and equity in our teaching, learning, and practice. Together we will dismantle systems, policy, and practices in health that oppress. The Black Lives Matter movement provides us with a ¿now window¿ of accepted dialogue to build a better, culturally safe Australian nursing and midwifery workforce, ensuring that Black Lives Matter in all aspects of health care.

Objectives: to examine the factors that motivate women who have had a previous caesarean section to consider planning a vaginal birth. Design: a qualitative descriptive study with thematic analysis, drawing on interviews with women participating in a two arm, un-blinded randomised controlled trial (RCT) of midwifery continuity of care for increasing the proportion of women planning VBAC. Setting: A Maternity Unit attached to a district hospital in an outer metropolitan area of Sydney, Australia. Participants: a purposive sample of 18 women participating in an RCT who had experienced previous caesarean section and had no contraindications for vaginal birth. Findings: These women were committed to natural birth and drew on their previous experience of caesarean section to highlight the downside of recovery post caesarean section. Decision making for these women was complex. During the decision-making process, women individualised the information provided to balance risk and chance within the context of their own circumstance. Supportive healthcare providers were important in motivating women towards vaginal birth and midwives were identified as being more supportive than obstetricians. Conclusions: Recovery post caesarean section is an important consideration that is under emphasised in the informed consent process. There is opportunity for midwives to contribute proactively in promoting vaginal birth for women who have experienced a previous caesarean section. Implications for practice: women should be assisted to make informed choices with balanced information that includes recovery from surgical birth. Models of care that include a significant role for midwives and strategies that proactively encourage vaginal birth for women after previous caesarean section are needed.

Objective: The psychological and emotional impact of a traumatic birth experience on clinicians is well-established. It is also known that emotions can generally influence decisions. However, it is not clear whether experiencing a birth trauma can affect the professional behaviour and decision-making of clinicians. This study explores the impact of birth trauma on clinical decision-making of midwives. Data Sources: Four databases (Medline, Scopus, CINAHL and ProQuest) were searched to identify English language studies published from 1990 to 2018. Due to the lack of studies with specific focus on clinical decision-making after birth trauma, we defined two main domains for our literature search. To be included, studies had to focus on either traumatic birth experience or clinical decision-making in midwifery. The findings of the two domains were then integrated. Study Selection: Of a total 2104 studies identified, 70 received full-text screening with 40 included in the review. Twenty-two articles were about traumatic birth events and 18 examined decision-making in midwifery. Data Extraction: Information were extracted on each article's purpose, study design, data collection, participants, definitions of birth trauma and the context in which clinical decisions were made. Results: Thematic analysis was conducted. The impact of birth trauma on midwives could be categorized into the following themes: psychological issues; professional concerns; changes in practice and positive impact. Review of literature indicated that clinical decision-making could be influenced through all these themes. Conclusion: Decision-making can be impacted by the midwife's affective state related to previous experience of birth trauma. The continuum of impact may vary from increased defensiveness to increased personal and professional growth. Being aware of this impact can help midwives to better manage their emotions while making decision after traumatic birth experiences.

Complementary and Alternative Medicine/Therapies (CAM) options have increasingly been used by pregnant women, however literature describing midwives¿ views and beliefs towards CAM is sparse. This study aimed to investigate Australian midwives¿ views and beliefs about CAM. Methods: A national survey of Australian College of Midwives midwife members (n = 3552) (UTSHREC 2015000614) included questions on midwives¿ views and support of CAM, and beliefs using a validated CAM Health Belief Questionnaire (CHBQ). Results: The response rate was 16%. Most respondents believed women should have the right to choose CAM (93.3%); and didn't view CAM a threat to public health (91.7%). Nearly half (49.5%) believed that their hospital/service did not have guidelines/procedures on CAM. The CHBQ mean score was 45.43 (SD9.98). Conclusion: Most respondents agreed with the fundamental beliefs of CAM. This study confirms the need for a national CAM policy for midwives; and research on midwives¿ CAM training.

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. Despite a recognition of the significance of this issue, women often do not receive the care they need and fall between the gap of maternity and mental health services. To address this, there is a call for reform in the way in which perinatal mental healthcare is delivered. This paper responds to this by exploring the role and competence of midwives in delivering mental healthcare. Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question ¿what is the nature of the evidence relevant to the provision of mental health interventions by midwives?¿ To identify studies, the databases PubMed, Maternity and Infant Care, Science Citation Index, Social Sciences Citation Index, Medline, Science Direct and CINAHL were searched from 2011 to 2018, and reference lists of included studies were examined. Studies relevant to the role of midwives in the management and treatment of perinatal mental health issues were included; studies focussed on screening and referral were excluded. Thirty papers met inclusion criteria, including studies about the knowledge, skills, and attitudes of midwives and student midwives; the effectiveness of educational interventions in improving knowledge and skills; the delivery of counselling or psychosocial interventions by midwives; and barriers and enablers to embedding midwife-led mental healthcare in practice. Synthesis of the included studies indicates that midwives are interested in providing mental health support, but lack the confidence, knowledge and training to do so. This deficit can be addressed with appropriate training and organisational support, and there is some evidence that midwife-led counselling interventions are effective. Further research is needed to test midwife-led interventions for women with perinatal mental health problems, and to develop and evaluate models of integrated perinatal mental healthcare.

Complementary and Alternative Medicine (CAM) have increasingly been used by pregnant women with a steady rise in interest by midwives. Literature describing CAM and self-help options midwives recommend to women experiencing a post-date pregnancy is sparse. This study aimed to investigate if Australian midwives¿ personal CAM use impacts on discussions and recommendations of CAM/Self-help strategies. Methodology/design: A survey of a national midwifery association midwifery members (n = 3,552) was undertaken at a midwifery conference (October 2015) and via e-bulletins (November 2015¿March 2016). The self-administered survey included questions on what self-help and CAM strategies midwives discuss and recommend to women with a post-date pregnancy, midwives¿ confidence levels on discussing or recommending CAM, midwives¿ own personal use of CAM. Findings: A total of 571 registered midwives completed the survey (16%). Demographics (age, years as a midwife, state of residence) reflected Australian midwives and the midwifery association membership. Most respondents discuss (91.2%) and recommend (88.6%) self-help/CAM strategies to women with a post-date pregnancy. The top five CAM recommended were Acupuncture (65.7%), Acupressure (58.1%), Raspberry Leaf (52.5%), Massage (38.9%) and Hypnosis/Calmbirthing/Hypnobirthing (35.7%). Midwives were more likely to discuss strategies if they personally used CAM (p <.001), were younger (p <.001) or had worked less years as midwives (p =.004). Midwives were more likely to recommend strategies if they used CAM in their own pregnancies (p =.001). Conclusion: Midwives¿ personal use of CAM influenced their discussions and recommendations of CAM/self-help strategies to women experiencing a post-date pregnancy. This study has implications for inclusion of CAM in midwifery education curricula.

Objective: Shoulder dystocia (SD) is an obstetric emergency which if not carefully diagnosed and managed, can contribute to lifelong neonatal morbidities. Despite current guidelines on the definition of SD (impaction of the fetal shoulder behind the maternal symphysis pubis and need for ancillary manoeuvres or head-body delivery interval (HBDI) >60 s) its accurate diagnosis requires clinical expertise as well as overall consideration of feto-maternal condition. Based on the literature available, our study aims to determine (1) the range of HBDI as an indicator of SD and (2) the neonatal complications occurring following prolonged HBDI in normal or SD-complicated births. Study design: A comprehensive literature search will be conducted in the following databases MEDLINE, CINAHL and Scopus (Elsevier) as well as international obstetric guidelines to find English language published data since 1970 that evaluate HBDI, prolonged HBDI and associated neonatal outcomes. Retrospective/prospective observational studies and randomized controlled trials will be recruited. As heterogeneity in definitions of SD among studies is expected, we will categorize our results according to the following two definitions: 1-Bony obstruction of fetal shoulder behind the maternal symphysis pubis or less commonly, posterior shoulder on sacral promontory and need for ancillary manoeuvres or 2- Head-body delivery interval (HBDI)> 60 s). Two reviewers will independently identify eligible studies, assess risk of bias and extract data based on predefined checklists. Outcomes of interest will be the HBDI in normal and SD-complicated births and associated neonatal consequences. Discussion: Findings of this systematic review will provide reliable information regarding (1) the interval between birth of the head and birth of the shoulders and (2) neonatal outcomes attributed to either true SD or prolonged HBDI. Our findings will add to the knowledge of whether prolonged HBDI is an appropriate definition for SD and whether/what level of prolongation of HBDI results in adverse neonatal outcomes. This increased understanding will better inform the clinical practice of midwives and obstetricians.

Background: Asthma affects 12.7% of pregnancies in Australia. Poorly controlled asthma is associated with increased maternal and infant morbidity and mortality. Optimal antenatal management of asthma during pregnancy has the potential to reduce complications relating to asthma. Evidence-based clinical practice guidelines help to translate health research findings into practice and when implemented can improve health outcomes. National and International guidelines currently provide recommendations for optimal asthma care in pregnancy. Aim: To appraise the existing asthma in pregnancy guidelines with respect to their evidence for recommendations, consistency of recommendations and appropriateness for clinical practice. Method: The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to appraise four English language asthma in pregnancy guidelines, published or updated between 2007 and 2016. The recommendations, range and level of evidence was analysed. Results: Two of the four guidelines scored highly in most domains of the appraisal. Many of the recommendations made in the appraised guidelines were consistent. Due to the lack of randomised controlled trials involving pregnant women with asthma, most recommendations were evidenced by consensus and expert opinion rather than high quality meta-analysis, systematic reviews of randomised controlled trials. Conclusion: The recommended antenatal asthma management was generally consistent among the guidelines but lacked clarity in some areas which then leave them open to interpretation. More randomised controlled trials involving pregnant women with asthma are required to fortify the recommendations made and asthma management guidelines should be included in Australian Antenatal Care Guidelines as they currently are not.

Background the viability of freestanding midwifery units in Australia is restricted, due to concerns over their safety, particularly for women and babies who, require transfer. Aim to compare the maternal and neonatal birth outcomes of women who planned, to give birth at freestanding midwifery units and subsequently, transferred to a tertiary maternity unit to the maternal and neonatal, outcomes of a low-risk cohort of women who planned to give birth in, tertiary maternity unit. Methods a descriptive study compared two groups of women with low-risk singleton, pregnancies who were less than 28 weeks pregnant at booking: women who, planned to give birth at a freestanding midwifery unit (n=494) who, transferred to a tertiary maternity unit during the antenatal, intrapartum or postnatal periods (n=260) and women who planned to give, birth at a tertiary maternity unit (n=3157). Primary outcomes were mode, of birth, Apgar score of less than 7 at 5¿minutes and admission to, special care nursery or neonatal intensive care. Key findings the proportion of women who experienced a caesarean section was lower, among the freestanding midwifery unit women who transferred during the, intrapartum/postnatal period compared to women in the tertiary maternity, unit group (16.1% versus 24.8% respectively). Other outcomes were, comparable between the cohorts. Rates of primary outcomes in relation to, stage of transfer varied when stratified by parity. discussion these descriptive results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women, with low risk pregnancies at the time of booking. A larger study, powered, to determine statistical significance of any differences in outcomes, is, required.

Objective to identify and describe the design characteristics of hospital birth rooms that support midwives and their practice. Design this study used a qualitative exploratory descriptive methodology underpinned by the theoretical approach of critical realism. Data was collected through 21 in-depth, face-to-face photo-elicitation interviews and a thematic analysis guided by study objectives and the aims of exploratory research was undertaken. Setting the study was set at a recently renovated tertiary hospital in a large Australian city. Participants participants were 16 registered midwives working in a tertiary hospital; seven in delivery suite and nine in birth centre settings. Experience as a midwife ranged from three to 39 years and the sample included midwives in diverse roles such as educator, student support and unit manager. Findings three design characteristics were identified that supported midwifery practice. They were friendliness, functionality and freedom. Friendly rooms reduced stress and increased midwives' feelings of safety. Functional rooms enabled choice and provided options to better meet the needs of labouring women. And freedom allowed for flexible, spontaneous and responsive midwifery practice. Conclusion hospital birth rooms that possess the characteristics of friendliness, functionality and freedom offer enhanced support for midwives and may therefore increase effective care provision. Implications for practice new and existing birth rooms can be designed or adapted to better support the wellbeing and effectiveness of midwives and may thereby enhance the quality of midwifery care delivered in the hospital. Quality midwifery care is associated with positive outcomes and experiences for labouring women. Further research is required to investigate the benefit that may be transmitted to women by implementing design intended to support and enhance midwifery practice.

Background Birth in primary midwife-led maternity units has been demonstrated to be a safe choice for well women anticipating a normal birth. The incidence of serious perinatal outcomes for these women is comparable to similarly low risk women, who choose to birth in hospital. New Zealand women have a choice of Lead Maternity Carer (LMC) and birthplace; home, primary birthing unit, or a base hospital, though not all women may have all these choices available locally. Women in rural and rural remote areas can also choose to birth in their rural primary maternity unit. A percentage of these women (approx. 15¿17%) will require transfer during labour, an event which can cause distress and often loss of midwifery continuity of care. Objective To explore retrospectively the choice of birth place decisions and the labour and birth experiences of a sample of women resident in remotely zoned, rural areas of the lower South Island of New Zealand. Design A purposive sample of women living in remote rural areas, recruited by advertising in local newspapers and flyers. Individual semi-structured interviews were digitally recorded using a pragmatic interpretive approach. The data (transcripts and field notes) were analysed using thematic and content analysis. Ethical approval was obtained from the Health and Disability Ethics Committee (HEDC) MEC/06/05/045. Participants Thirteen women consented to participate. Each was resident in a remote rural area having given birth in the previous 18 months. The women had been well during their pregnancies and at the onset of labour had anticipated a spontaneous vaginal birth. Setting Rural remote zoned areas in Otago and Southland in the South Island of New Zealand Findings Five women planned to birth in a regional hospital and eight chose their nearest rural primary maternity unit. All of the women were aware of the possibility of transfer and had made their decision about their birthplace based on their perception of their personal safety, and in consideration of their distance from specialist care. Themes included, deciding about the safest place to give birth; making the decision to transfer; experiencing transfer in labour, and reflecting on their birth experience and considering future birthplace choices. Conclusions and implications for practice and policy The experiences of the women show that for some, distance from a base hospital influences their place of birth decisions in remote rural areas of New Zealand and increases the distress for those needing to transfer over large distances. These experiences can result in women choosing, or needing to make different choices for subsequent births; the consequences of which impact on the future sustainability of midwifery services in remote rural areas, a challenge which resonates with maternity service provision internationally. While choices about birth place cannot be reliably predicted, creative solutions are needed to provide rural midwifery care and birth options for women and more timely and efficient transfer services when required.

Background Caseload midwifery is expanding in Denmark. There is a need for elaborating in-depth, how caseload midwifery influences the partner and the woman during childbirth and how this model of care influences the early phases of labour. Aim To follow, explore and elaborate women's and their partner's experiences of caseload midwifery. Methods Phenomenology of practice was the analytical approach. The methodology was inspired by ethnography, and applied methods were field observations followed by interviews. Ten couples participated in the study. Most of the couples were observed from the onset of labour until childbirth. Afterwards, the couples were interviewed. Findings The transition from home to hospital in early labour was experienced as positive. During birth, the partner felt involved and included by the midwife. The midwives remembered and recognized the couple's stories and wishes for childbirth and therefore they felt regarded as ¿more than numbers¿. Irrespective of different kinds of vulnerability or challenges among the participants, the relationship was named a professional friendship, characterised by equality and inclusiveness. One drawback of caseload midwifery was that the woman was at risk of being disappointed if her expectations of having a known midwife at birth were not fulfilled. Key conclusions From the perspective of women and their partners, attending caseload midwifery meant being recognised and cared for as an individual. The partner felt included and acknowledged and experienced working in a team with the midwife. Caseload midwifery was able to solve problems concerning labour onset or gaining access to the labour ward.

Background Breastfeeding has many known benefits yet its support across Australian health systems was suboptimal throughout the 20th Century. The World Health Organization launched a global health promotion strategy to help create a ¿breastfeeding culture¿. Research on the programme has revealed multiple barriers since implementation. Aim To analyse the sociopolitical challenges associated with implementing a global programme into a national setting via an examination of the influences on the early period of implementation of the Baby Friendly Hospital Initiative in Australia. Methods A focused historical document analysis was attended as part of an instrumental case study. A purposeful sampling strategy obtained a comprehensive sample of public and private documents related to the introduction of the BFHI in Australia. Analysis was informed by a ¿documents as commentary¿ approach to gain insight into individual and collective social practices not otherwise observable. Findings Four major themes were identified: ¿a breastfeeding culture¿; ¿resource implications¿; ¿ambivalent support for breastfeeding and the BFHI¿ and ¿business versus advocacy¿. ¿A breastfeeding culture¿ included several subthemes. No tangible support for breastfeeding generally, or the Baby Friendly Hospital Initiative specifically, was identified. Australian policy did not follow international recommendations. There were no financial or policy incentives for BFHI implementation. Conclusions Key stakeholders¿ decisions negatively impacted on the Baby Friendly Hospital Initiative at a crucial time in its implementation in Australia. The potential impact of the programme was not realised, representing a missed opportunity to establish and provide sustainable standardised breastfeeding support to Australian women and their families.

Objective To identify the predominant culture of an organisation which could then assess readiness for change. Design An exploratory design using the Competing Values Framework (CVF) as a self-administered survey tool. Setting The Maternity Unit in one Australian metropolitan tertiary referral hospital. Subjects All 120 clinicians (100 midwives and 20 obstetricians) employed in the maternity service were invited to participate; 26% responded. Main outcome measure The identification of the predominant culture of an organisation to assess readiness for change prior to the implementation of a new policy. Results The predominant culture of this maternity unit, as described by those who responded to the survey, was one of hierarchy with a focus on rules and regulations and less focus on innovation, flexibility and teamwork. These results suggest that this unit did not have readiness to change. Conclusion There is value in undertaking preparatory work to gain a better understanding of the characteristics of an organisation prior to designing and implementing change. This understanding can influence additional preliminary work that may be required to increase the readiness for change and therefore increase the opportunity for successful change. The CVF is a useful tool to identify the predominant culture and characteristics of an organisation that could influence the success of change.

Objective: To explore inhibiting and facilitating design factors influencing childbirth supporters¿ experiences. Background: Birthing women benefit from the continuous, cooperative presence of supporters. However, little research has investigated how birth room design facilitates or inhibits supporters¿ role navigation. Methods: We conducted an exploratory video ethnographic single case study of childbirth supporters¿ experiences, within an Australian hospital birth environment. Video, field notes, and video-cued reflexive interviews with the woman, her midwives, and supporters were thematically analyzed using ethnographic/symbolic interactionist perspectives to frame supporters¿ understandings. Results: Findings suggest supporters¿ experiences are complex, made more complicated by sparse understanding or accommodation of their needs in the built environment. Supporters¿ presence and roles are not facilitated by the physical space; they experience ¿an unbelonging paradox¿ of being needed, yet uncertain and ¿in the way¿ during ¿tenuous nest-building¿ activities. Conclusions: Suggested design guidelines to facilitate supporters¿ well-being and their roles in designed hospital birth spaces are provided.

Objective: this study examined images of birth rooms in developed countries to analyse the messages and visual discourse being communicated through images. Design: a small qualitative study using Kress and van Leeuwen's (2006) social semiotic theoretical framework for image analysis, a form of discourse analysis. Setting/participants: forty images of birth rooms were collected in 2013 from Google Images, Flickr, Wikimedia Commons and midwifery colleagues. The images were from obstetric units, alongside and freestanding midwifery units located in developed countries (Australia, Canada, Europe, New Zealand, United Kingdom and the United States of America). Main findings: findings demonstrated three kinds of birth room images; the technological, the 'homelike', and the hybrid domesticated birth room. The most dominant was the technological birth room, with a focus on the labour bed and medical equipment. The visual messages from images of the technological birth room reinforce the notion that the bed is the most appropriate place to give birth and the use of medical equipment is intrinsically involved in the birth process. Childbirth is thus construed as risky/dangerous. Key conclusions and implications for practice: as images on the Internet inform and persuade society about stereotypical behaviours, the trends of our time and sociocultural norms, it is important to recognise images of the technological birth room on the Internet may be influential in dictating women's attitudes, choices and behaviour, before they enter the birth room.

Objective: the aim of this study is to advance knowledge about the working and living conditions of midwives in caseload midwifery and how this model of care is embedded in a standard maternity unit. This led to two research questions: 1) What constitutes caseload midwifery from the perspectives of the midwives? 2) How do midwives experience working in caseload midwifery? Design and setting: phenomenology of practice was the analytical approach to this qualitative study of caseload midwifery in Northern Denmark. The methodology was inspired by ethnography, and applied methods were field observations followed by interviews. Participants: thirteen midwives working in caseloads were observed during one or two days in the antenatal clinic and were interviewed at a later occasion. Findings: being recognised and the feeling of doing high quality care generate high job satisfaction. The obligation and pressure to perform well and the disadvantages to the midwives' personal lives are counterbalanced by the feeling of doing a meaningful and important job. Working in caseload midwifery creates a feeling of working in a self-governing model within the public hospital, without losing the technological benefits of a modern birth unit. Midwives in caseload midwifery worked on welcoming and including all pregnant women allocated to their care; even women/families where relationships with the midwives were challenging were recognised and respected. Key conclusions: caseload midwifery is a work-form with an embedded and inevitable commitment and obligation that brings forward the midwife's desire to do her utmost and in return receive appreciation, social recognition and a meaningful job with great job satisfaction. There is a balance between the advantages of a meaningful job and the disadvantages for the personal life of the midwife, but benefits were found to outweigh disadvantages. Implications for practice: In expanding caseload midwifery, it is necessary to understand that the midwives' personal lives need to be prepared for this work-form. The number of women per full time midwife has to be surveilled as job-satisfaction is dependent on the midwives' ability of fulfilling expectations of being present at women's births.

Background limited efforts have been made to understand the complex relationships between women's experiences of birth and the influence of the design and environment of a birth space. Domestic aesthetics in a birth space are believed to be an important aspect of optimal birth unit design. Aim to explore the concept of domesticity within the birth space. The specific objectives were to explore, describe and compare birth spaces with different domestic characteristics and subsequently, how laboring women worked within these spaces during the labour process. This project was situated within a larger ongoing body of work exploring birth unit design. Method a qualitative approach, using the techniques of video ethnography and reflexive interviewing, was used. Video data consisted of films of the labours of six Australian women who gave birth in 2012. Filming took place in two different tertiary hospitals in Sydney NSW (n=5 women), as well as a stand-alone Birth Centre (n=1 woman). Video footage of a woman labouring at home was used to compare and contrast women's experiences. Latent content analysis was used to analyse the data set. In addition there were 17 one-hour video-reflexive interviews that were audio-taped and fully transcribed (nine interviews with women and/or their support people and eight with midwives). Field note data accompanied both the video recording as well as the reflexive interviews. Findings in general, women labouring in conventional hospital labour and birth rooms acted and interacted with the environment in a passive way. The spaces clearly did not resemble homely or ¿domestic¿ spaces. This forced women to adapt to the space. In essence all but one of the women labouring and birthing in these spaces took on the role of a ¿patient¿. One participant responded quite differently to the conventional hospital space. ¿Domestication of the space¿ was the mechanism this woman used to retain a sense of ownership within the birth space. In contrast, in the domestic birth environments (Birth Centre and home) women effortlessly claimed ownership of the space, expressing their identity in a myriad of ways. In these domestic spaces, women were not required to change or modify their birth spaces as the design, furnishings and semiotics of the space openly encouraged them to be active, creative and take ownership of the space. Conclusion the findings of this study add to the existing literature on birth unit design and more specifically contribute to an understanding of how the features of domesticity within the birth setting may shape the experience of labouring women and their care providers. The evidence gained from the study will assist in the ongoing movement to humanise birth spaces and develop further understandings of how home-like birth spaces should look. Those designing, building, furnishing, managing, accessing and working in Birthing Services could all benefit from the consideration of how environments designed for the care of birthing women, may be affecting the outcomes and experiences of women and their families.

AIM: To explore the use and application of case study research in midwifery.

Background: Antenatal care is one of the key preventive health services used around the world. In most Western countries, antenatal care traditionally involves a schedule of one-to-one visits with a care provider. A different way of providing antenatal care involves use of a group model. Objectives: 1. To compare the effects of group antenatal care versus conventional antenatal care on psychosocial, physiological, labour and birth outcomes for women and their babies. 2. To compare the effects of group antenatal care versus conventional antenatal care on care provider satisfaction. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), contacted experts in the field and reviewed the reference lists of retrieved studies. Selection criteria: All identified published, unpublished and ongoing randomised and quasi-randomised controlled trials comparing group antenatal care with conventional antenatal care were included. Cluster-randomised trials were eligible, and one has been included. Cross-over trials were not eligible. Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias and extracted data; all review authors checked data for accuracy. Main results: We included four studies (2350 women). The overall risk of bias for the included studies was assessed as acceptable in two studies and good in two studies. No statistically significant differences were observed between women who received group antenatal care and those given standard individual antenatal care for the primary outcome of preterm birth (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.57 to 1.00; three trials; N = 1888). The proportion of low-birthweight (less than 2500 g) babies was similar between groups (RR 0.92, 95% CI 0.68 to 1.23; three trials; N = 1935). No group differences were noted for the primary outcomes small-for-gestational age (RR 0.92, 95% CI 0.68 to 1.24; two trials; N = 1473) and perinatal mortality (RR 0.63, 95% CI 0.32 to 1.25; three trials; N = 1943). Satisfaction was rated as high among women who were allocated to group antenatal care, but this outcome was measured in only one trial. In this trial, mean satisfaction with care in the group given antenatal care was almost five times greater than that reported by those allocated to standard care (mean difference 4.90, 95% CI 3.10 to 6.70; one study; N = 993). No differences in neonatal intensive care admission, initiation of breastfeeding or spontaneous vaginal birth were observed between groups. Several outcomes related to stress and depression were reported in one trial. No differences between groups were observed for any of these outcomes. No data were available on the effects of group antenatal care on care provider satisfaction. We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess evidence for seven prespecified outcomes; results ranged from low quality (perinatal mortality) to moderate quality (preterm birth, low birthweight, neonatal intensive care unit admission, breastfeeding initiation) to high quality (satisfaction with antenatal care, spontaneous vaginal birth). Authors' conclusions: Available evidence suggests that group antenatal care is positively viewed by women and is associated with no adverse outcomes for them or for their babies. No differences in the rate of preterm birth were reported when women received group antenatal care. This review is limited because of the small numbers of studies and women, and because one study contributed 42% of the women. Most of the analyses are based on a single study. Additional research is required to determine whether group antenatal care is associated with significant benefit in terms of preterm birth or birthweight.

Little is known about how the physical design of a birthing unit can influence the experiences of labour and birth for women, their supporters and midwives. We proposed that an interdisciplinary approach (disciplines of midwifery, architecture, design, communication and public health) was likely to be the most effective way to better understand the complexities and interactions of design, behaviour, communication and experiences. In this methodological paper we aim to provide a roadmap that other researchers may find helpful when considering the use of video as a data collection technique, especially in the study of the powerful and intimate setting of childbirth. The paper also outlines our process for engaging both researchers and participants in reviewing video footage with the aim to contribute multiple perspectives to the analysis process.

Background: The outcomes for women who give birth in hospital compared with at home are the subject of ongoing debate. We aimed to determine whether a retrospective linked data study using routinely collected data was a viable means to compare perinatal and maternal outcomes and interventions in labour by planned place of birth at the onset of labour in one Australian state.Methods: A population-based cohort study was undertaken using routinely collected linked data from the New South Wales Perinatal Data Collection, Admitted Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages and the Australian Bureau of Statistics. Eight years of data provided a sample size of 258,161 full-term women and their infants. The primary outcome was a composite outcome of neonatal mortality and morbidity as used in the Birthplace in England study.Results: Women who planned to give birth in a birth centre or at home were significantly more likely to have a normal labour and birth compared with women in the labour ward group. There were no statistically significant differences in stillbirth and early neonatal deaths between the three groups, although we had insufficient statistical power to test reliably for these differences.Conclusion: This study provides information to assist the development and evaluation of different places of birth across Australia. It is feasible to examine perinatal and maternal outcomes by planned place of birth using routinely collected linked data, although very large data sets will be required to measure rare outcomes associated with place of birth in a low risk population, especially in countries like Australia where homebirth rates are low. © 2014 Homer et al.; licensee BioMed Central Ltd.

Studies have identified that the practices of maternity facilities and health professionals are crucial to women's experience of support and breastfeeding 'success'. The Baby Friendly Hospital Initiative (BFHI) was launched globally in 1991 to protect, promote and support breastfeeding. While a direct causal effect has not been established and critics suggest the rhetoric conflicts with women's lived experiences as new mothers, a positive association between the Initiative and breastfeeding prevalence is apparent. Internationally, impact studies have demonstrated that where the Initiative is well integrated, there is an increase in rates of breastfeeding initiation and, to a lesser extent, duration. In consideration of the known health risks associated with the use of artificial baby milks this would suggest that BFHI implementation and accreditation should be a desirable strategy for committed health facilities. However, a variation in both BFHI uptake and breastfeeding prevalence between nations has been reported. This narrative review critically discusses a variety of issues relevant to the uptake and support of breastfeeding and the BFHI, utilising Australia as a case study. Whilst it enjoys 'in principle' policy support, Australia also suffers from a lack of uniformity in uptake and perception of the benefits of BFHI at all levels of the health system. Australian and international studies have identified similar enablers and barriers to implementation.

Background Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identifi ed risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. Methods In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the fi rst booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by inten tion to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. Findings Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0¿88, 95% CI 0¿70-1¿10; p=0¿26). The proportion of women who had elective caesarean sections (before onset of labour) diff ered signifi cantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0¿72, 95% CI 0¿52-0¿99; p=0¿05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0¿90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0¿08) and epidural use (314 [36%] vs 304 [35%]; p=0¿54). Neonatal outcomes did not diff er between the groups. Total cost of care per woman was AUS$566¿74 (95% 106¿17-1027¿30; p=0¿02) less for caseload midwifery than for standard maternity care. Interpretation Our results show that for women of any risk, caseload midwifery is safe and cost-effective.