The barometer of moral distress in midwifery: A pilot study

BACKGROUND

Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery.

AIM

The aim of this study was to pilot the Barometer of Moral Distress in Midwifery.

METHODS

This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity.

FINDINGS

A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores.

DISCUSSION/CONCLUSION

This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress.

Evaluation of a pilot online education program to develop midwives' knowledge, skill and confidence in perinatal mental health in rural South Australia

One in five women will experience perinatal anxiety and/or depression. In South Australia, a rural health service identified a high proportion of women with risk of perinatal mental health challenges and sought additional education for midwives. In response, a six-week facilitated, online perinatal mental health education program (e-PMHEP) was piloted.

AIM

The aim of this study was to evaluate the effectiveness of the (e-PMHEP) for rural midwives, nurses and Aboriginal maternal infant care practitioners.

METHOD

Program evaluation incorporated a validated online pre/post survey to assess self-reported knowledge, skill and confidence regarding perinatal mental healthcare. Additional questions sought feedback on satisfaction and feasibility.

FINDINGS

Sixteen participants from rural South Australia engaged in the project from June to August 2022. Twelve participants completed the online pre/post survey. The overall pre/post knowledge scores were statistically significant (t = 2.73, 8df, p = 0.025) with improvement from the pre to post-test. Pre/post data also showed a measurable increase in confidence and skills. All respondents agreed that the content addressed their learning needs and would recommend this program to other practitioners.

DISCUSSION

The e-PMHEP appeared beneficial in developing knowledge, skills and confidence regarding perinatal mental healthcare in rural midwives and practitioners. Only a third of practitioners routinely developed a mental health care plan with women. Key strengths of the program included the accessible content, and the combination of an experienced mental health clinician and a facilitator with lived experience.

CONCLUSION

Providing an accessible, facilitated online perinatal mental health education program could be beneficial for rural midwives.

'There is no other option': Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia

INTRODUCTION

In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken.

OBJECTIVE

The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers.

DESIGN

The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services.

FINDINGS

The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'.

DISCUSSION

All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals.

CONCLUSION

This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'.

Yourtime: The development and pilot of a perinatal mental wellbeing digital tool using a co-design approach

INTRODUCTION

Maternal anxiety and depression are major public health issues with prevalence as high as one in five women. There is a need to focus on preventative strategies to enable women to self-monitor their mental health status during pregnancy and postnatally.

AIM

To co-design and test a perinatal mental health digital tool to enable women to self-monitor their mental wellbeing during pregnancy and early parenting and promote positive self-care strategies.

METHODS AND ETHICS

A sequential mixed methods study utilising two stages 1) co-design workshops; 2) fit for purpose pilot with women through a purpose designed survey to evaluate acceptability, useability, functionality, and satisfaction.

FINDINGS

Mothers, midwives, design researchers and students, participated in co-designing a digital tool and prototype application, YourTime. Fourteen participants engaged in the pilot, with all women agreeing that the tool would be beneficial in alerting them to changes in mental wellbeing. Seventy-seven percent agreed that this prototype had the potential to positively affect wellbeing during the perinatal period.

DISCUSSION

The need to develop a perinatal mental health digital tool that enables women to self-monitor their wellbeing was identified. Women reported the YourTime app offered an acceptable and effective means to self-assess and monitor their wellbeing.

CONCLUSION

The YourTime app responds to the growing agenda for digital approaches to address perinatal mental health challenges. The pilot study demonstrated that the app offered potential to alert women to changes in mental wellbeing, but functionality need further development.

Moral distress in midwifery practice: A Delphi study

BACKGROUND

Moral distress is a psychological concept that describes the harm associated with actions or inactions that oppose an individuals' moral beliefs. Moral distress is linked to moral compromise in the workplace that may negatively impact mental wellbeing. Current tools available to assess moral distress are not specific for the Australian health care system or midwifery practice.

AIM

The aim of this study was to develop a list of situational and outcome statements associated with moral compromise and levels of moral distress in midwifery to inform the development of a tool to measure levels of moral distress in midwives.

METHODS

This e-Delphi study was the third stage of a sequential exploratory mixed-methods study. Using an online strategy, three iterative rounds of e-Delphi were collected and analysed for consensus on situations leading to moral distress and the associated psychological outcomes.

FINDINGS

Twenty participants contributed across the three rounds. Consensus was met in 40 morally compromising situation statements. The highest level of consensus related to excessive workloads and the associated negative impact of this on women and families. Consensus on outcomes following exposure to morally distressing situations led to the development of a continuum scale from moral frustration to moral injury.

DISCUSSION/CONCLUSION

This is the first study to use a consensus method to establish different levels of moral compromise, frustration, distress, and injury in midwifery practice. The findings of this study contribute to a growing body of literature that supports the concept of moral distress occurring across a continuum.

The role of midwives in supporting the development of the mother-infant relationship: a scoping review

BACKGROUND

The mother-infant relationship is complex and dynamic, informing the psychological development of the infant through bonding and attachment. Positive early interactions influence the quality of this relationship. Midwives are well placed to support the developing relationship between the mother and baby, yet there has been limited research exploring the role of the midwife in this context.

AIM

To explore interventions that have been provided by the midwife which support the development of the maternal-fetal or mother-infant relationship amongst a low-risk population from pregnancy, and up to six weeks postnatal. The review also sought to understand the types of interventions developed, format and delivery, outcomes measured and if cultural considerations had been incorporated.

METHODS

A scoping review of the research literature was undertaken using the Joanna Briggs Institute framework. Five online databases were searched for relevant articles published in English from 2000 to 2021.

FINDINGS

Sixteen articles met the inclusion criteria. Three themes emerged: (1) viewing the fetus as separate from the mother, (2) focused activities on the maternal-infant relationship and (3) targeted educational interventions.

DISCUSSION

Providing focused activities and targeted education during the pre and postnatal periods support the development of the mother-infant relationship. Significantly, there was insufficient research that considered the influence of culture in supporting the mother-infant relationship.

CONCLUSION

Further research is required to develop interventions that include a diverse sample to ensure culturally appropriate activities can be integrated into care during pregnancy and/or the postnatal period provided by midwives.

Examining the transformation of midwifery education in Australia to inform future directions: An integrative review

BACKGROUND

Integral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions.

AIM

To critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia.

METHODS

A structured integrative literature review using Whittemore and Knafl's five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results.

FINDINGS

The literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education.

DISCUSSION

Extensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality.

CONCLUSION

There is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services.

Exploring moral distress in Australian midwifery practice

PROBLEM

Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.

BACKGROUND

Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.

AIM

To explore Australian midwives experience and consequences of moral distress.

METHODS

Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.

FINDINGS

Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.

DISCUSSION

It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.

CONCLUSION

This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Moral distress in midwifery practice: A concept analysis

Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers' evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as 'a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments'. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress.

Using Co-design to Explore How Midwives Can Support the Emerging Mother-Infant Relationship During the Early Postnatal Period: Protocol for a Mixed Methods Study

Background

The postnatal period can be a challenging time for women, with mothers experiencing a range of emotions. As a woman transitions to motherhood, she adjusts to a new sense of self and forms a new relationship with her infant. Becoming a mother is a complex cognitive and social process that is unique for each woman and is influenced and shaped by culture. The emerging mother-infant relationship is a significant factor in maternal well-being and infant development, with the bond between the mother and her baby being critical to the development of secure attachment. It has been recognized that the strength of this relationship is the main predictor of how well a child will do throughout life. There has been a global focus on the importance of the first 1000 days, with Australia identifying this as a national priority. Midwives are ideally placed to support mothers during the development of the mother-infant relationship, providing care through the early postnatal period, which has been identified as a sensitive period for the development of the mother-infant relationship.

Objective

The aim of this study is to explore how midwives can support the emerging mother-infant relationship in the context of cultural diversity and develop an appropriate co-designed intervention in the early postnatal period.

Methods

This study will use a mixed method approach, specifically the exploratory sequential design (intervention development variant). This study will be undertaken in 3 phases: 1 qualitative phase, which is followed by 2 quantitative phases. Phase 1 will include a scoping review to explore interventions that have influenced the development of the mother-infant relationship, and then, interviews will be undertaken with women exploring their early experiences of motherhood, followed by 3 co-design workshops. The workshops will engage with multilevel stakeholder representatives where, through partnership and participation, they will propose and develop an intervention to support the emerging mother-infant relationship. Phase 2 will develop and pilot 2 purpose-designed evaluation surveys to evaluate the co-designed intervention from the perspective of both mothers and midwives. Phase 3 will implement and evaluate the co-designed intervention using pre- and postmeasures and feedback from the purpose-designed surveys.

Results

Phase 1 has commenced and is expected to be completed by August 2021. Phase 2 is expected to be completed by September 2021, with phase 3 commencing in October 2021. The study will be completed by March 2023.

Conclusions

The results of this study will be shared with a variety of audiences and will contribute to the body of knowledge on the mother-infant relationship, potentially improving the understanding of this relationship for women and midwives. This may result in improved strategies for care, with mothers benefiting from enhanced experience and satisfaction during the early postnatal period.

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia

BACKGROUND

The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.

METHODS

A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant's commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.

RESULTS

Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12-60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, "People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements "People who work here are determined to implement this change", "People who work here want to implement this change", and "People who work here are committed to implementing this change.

CONCLUSION

Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Women's Barriers to Weight Loss, Perception of Future Diabetes Risk and Opinions of Diet Strategies Following Gestational Diabetes: An Online Survey

Weight loss after gestational diabetes (GDM) reduces the risk of type 2 diabetes (T2DM); however, weight loss remains challenging in this population. In order to explore perceptions of T2DM risk, barriers to weight loss, and views of diet strategies in women with previous GDM, a cross-sectional online survey of n = 429 women in Australia aged ≥18 years with previous GDM was conducted. Opinions of intermittent energy restriction (IER) were of interest. Seventy-five percent of responders (n = 322) had overweight or obesity, and 34% (n = 144) believed they had a high risk of developing T2DM. Within the Theoretical Domains Framework, barriers to weight loss were prominently related to Environmental Context and Resources, Beliefs about Capabilities, and Behavioural Regulation. Exercising was the most tried method of weight loss over other diet strategies (71%, n = 234) and weight loss support by a dietician was appealing as individual appointments (65%, n = 242) or an online program (54%, n = 200). Most women (73%, n = 284) had heard of IER (the "5:2 diet"), but only 12% (n = 34) had tried it. Open comments (n = 100) revealed mixed views of IER. Women in Australia with previous GDM were found to lack a self-perceived high risk of developing T2DM and expressed barriers to weight loss related to their family environment, beliefs about their capabilities and behavioural regulation. IER is appealing for some women with previous GDM; however, views vary.

Midwifery-led care in South Australia: Looking back to move forward

BACKGROUND

From the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.

AIM

To better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.

METHODS

Semi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.

FINDINGS

Three overarching themes and several sub-themes were identified, these included: 'Midwifery suffragettes' which explored 'activism', 'adversity' and 'advocacy'; 'Building bridges' captured the importance of 'gathering midwives', a 'movement of women' and 'champions and influencers'; and 'Recognising midwifery' identified the strong 'sense of identity' needed to outface 'ignorance and opposition' and the importance of 'role reformation'.

CONCLUSION

These midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.

Identifying the priorities for midwifery education across Australia and New Zealand: A Delphi study

PROBLEM

In countries where education programmes are assessed as meeting international standards there is limited knowledge about the challenges facing midwifery education.

BACKGROUND/AIM

The positive impact of quality midwifery education on maternal and newborn health is acknowledged by the World Health Organisation. However, there is limited research identifying the issues faced in providing quality midwifery education. The aim of this study was to identify the challenges and determine priority projects to strengthen midwifery education across Australia and New Zealand.

METHODS

A two-round Delphi study with experts in midwifery education was undertaken.

FINDINGS

In round one, 85 participants identified an initial 366 issues for midwifery education. Through thematic content analysis these were categorised into 89 statements reflecting five major themes: In round two, 105 midwifery experts from Australia n=86 (79%) and New Zealand n=23 (21%) rated the 89 statements in order of priority. Across the combined data (Australia and New Zealand) a total of 19 statements gained consensus of ≥80%.

DISCUSSION

Five priority themes were identified including; (1) enabling success of First Peoples/Māori midwifery students; (2) increasing the visibility and influence of midwifery within regulation, accreditation and university governance; (3) determining how best to deliver the clinical practicum component of programmes; (4) reviewing midwifery programmes to enhance design, content and delivery; and (5) ongoing education and support for the midwifery workforce.

CONCLUSION

In Australia and New Zealand, it is imperative that collaborative work is undertaken to design and action identified projects addressing these priorities.

Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016

BACKGROUND

Birth Centres (BC) are underpinned by a philosophy of woman- centred care and were pivotal in growing models of midwifery-led care in South Australia (SA).

AIM

To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades.

METHODS

The SA Perinatal Statistics Collection was used to describe women birthing from 1998 to 2016. Number of births through midwifery-led services from 2004 to 2016 were obtained from unit managers. Analyses are descriptive.

FINDINGS

Women who birthed in BC in SA from 1998 to 2016 comprised approximately 6% of all births per year, and numbers have remained static. Three BC models operate in SA, all with different capacity. Proportionally, women not born in Australia are as likely to birth in BC as labour wards. The proportion of women who received midwifery-led care (whether affiliated with a BC or not), increased from 8.3% in 1998 to 19.2% of all births in 2016. Of the women who received midwifery-led care in 2016, 15.3% went on to birth in a midwifery-led model of care.

CONCLUSION

Whilst the overall number of BC births has not increased, women seeking midwifery-led care has more than doubled over the past two decades. BC encompass the midwifery philosophy, quality of care, and a physical home-like environment. The BC models in SA are managed through the three tertiary maternity units enabling women to access publicly funded midwifery care and should be more widely available.

Simulation in midwifery education: A descriptive explorative study exploring students' knowledge, confidence and skills in the care of the preterm neonate

Undergraduate midwifery programs across Australia have embedded simulation into their curriculum although there is limited but emerging evidence to support the use of simulation as an effective teaching strategy. The purpose of this study was to evaluate the impact that a simulated learning activity (insertion and management of a neonatal nasogastric tube), had on midwifery students' knowledge, confidence and skills post-simulation, and on completion of a clinical placement. A descriptive explorative study was undertaken in two phases. Phase 1: Midwifery students (n = 60) completed a purpose-designed questionnaire to assess their knowledge, confidence and skills, pre and post simulation. Phase 2: Students (n = 46) repeated the questionnaire to reassess their knowledge, confidence and skills after the completion of a neonatal nursery placement. The findings demonstrate that simulation is an effective learning strategy in an undergraduate midwifery program. Students' knowledge, confidence and skills increased significantly post-simulation activity (p0.001). A further increase in these areas was noted post-placement. Key aspects that contributed to student learning included; the demonstrators' level of knowledge, expertise and currency of practice, as well as the role the student assumes in the simulation activity.

A public e-survey to explore community understanding of the role of the midwife in Australia

INTRODUCTION

There is compelling evidence that when a woman sees the same midwife there are better outcomes. Yet in Australia, access to midwifery continuity of care remains limited. There are a number of reasons for this but one barrier appears to be a lack of public understanding regarding the role of the midwife. This study undertook an e-survey to explore Australian public perceptions of the role of the midwife.

METHODS

A public opinion sample e-survey, using an exploratory design, a Likert scale and open-ended questions, was distributed through social media over six weeks. The survey was open to Australian residents and was completed by 1657 participants. Of these, 96.9% identified as female and 82.1% of participants had children.

RESULTS

Nearly half of the participants believed that a woman must see a doctor during pregnancy and after birth, compared to 21.9% during birth. Many participants described midwives as caring and supportive but there was a lack of understanding about their level of skill and expertise. A dominant theme was the alignment of medical care with safety and the perception that medical practitioners reduce risk. These misperceptions may impact on women making an informed choice regarding midwifery model of care in Australia.

CONCLUSIONS

There is an underlying public narrative whereby the public primarily associate midwives with birth and perceive them as assistants rather than lead care providers. The study findings informed a public awareness campaign in South Australia conducted to educate the public’s understanding of the role of the midwife.

Shared decision aids in pregnancy care: A scoping review

BACKGROUND

Shared decision making in pregnancy, labour, and birth is vital to woman-centred care and despite strong evidence for the effectiveness of shared decision making in pregnancy care, practical uptake has been slow.

DESIGN AND AIM

This scoping review aimed to identify and describe effective and appropriate shared decision aids designed to be provided to women in the antenatal period to assist them in making informed decisions for both pregnancy and birth. Two questions guided the enquiry: (i) what shared decision aids for pregnancy and perinatal care are of appropriate quality and feasibility for application in Australia? (ii) which of these decision aids have been shown to be effective and appropriate for Aboriginal and Torres Strait Islander peoples, culturally diverse women, or those with low literacy?

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) was used to conduct the review. Five key databases and selected grey literature sources were examined. English language evidence from Australia, Europe, Canada, United Kingdom, New Zealand, and United States of America produced from 2009 was eligible for inclusion, checked against apriori inclusion criteria, and assessed for quality and usability using the International Patient Decision Aid Standards.

RESULTS

From a total of 5,209 search results, 35 sources of evidence reporting on 27 decision aids were included following title/abstract and full-text review. Most of the decision aids concerned decisions around birth (52%, n = 14) or antenatal screening 37% (n = 10). The quality of the decision aids was moderate to high, with most communicating risks, benefits, and choice pathways via a mix of Likert-style scales, quizzes, and pictures or graphs. Use of decision aids resulted in significant reductions in decisional conflict and increased knowledge. The format of decision aids appeared to have no effect on these outcomes, indicating that paper-based are as effective as video- or audio-based decision aids. Eleven decision aids were suitable for low literacy or low health literacy women, and six were either developed for culturally diverse groups or have been translated into other languages. No decision aids found were specific to Aboriginal and Torres Strait Islander peoples.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The 27 decision aids are readily adoptable into westernised healthcare settings and can be used by midwives or multidisciplinary teams in conjunction with women. Decision aids are designed to support women, and families to arrive at informed choices and supplement the decision-making process rather than to replace consumer-healthcare professional interaction. If given before an appointment, high quality decision aids can increase a woman's familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflict and increasing knowledge.

Women's Barriers to Weight Loss, Knowledge of Future Diabetes Risk and Opinions of Diet Strategies Following Gestational Diabetes: An Online Survey (OR08-01-19)

Objectives

Weight loss after gestational diabetes (GDM) significantly reduces the risk of developing type 2 diabetes (T2DM) however weight loss is not easily achieved or maintained. The purpose of this survey was to examine knowledge of future risk of T2DM after GDM, barriers to weight loss and to identify diet strategies that these women feel might work for them. Opinions of intermittent energy restriction (IER) were of particular interest.

Methods

Australian women aged ≥18 years who ever had GDM were invited to participate in this cross-sectional online survey. The survey was developed by a dietitian using the Theoretical Domains Framework and underwent expert review (n = 6) and piloted (n = 20) prior to the final survey being run.

Results

There were 429 partial and 328 complete responses (age 37.2 ± 7.2 years, n = 429, years post GDM 4.9 ± 6.3 years, n = 428, BMI 30.9 ± 7.3 kg/m2n = 394). Overweight (n = 110) or obese (n = 200) responders mostly knew they were overweight and three-quarters thought they were either high (n = 144, 33.6%) or moderate risk (n = 176, 41.1%) for developing T2DM. Most women reported they knew what sorts of food to eat to lose weight (n = 332, 86.7%), that their families would support them (n = 320, 87%) and they were motivated to lose weight (n = 213, 58.4%). The most common barriers were family responsibilities taking priority (n = 240, 63%) and finding it hard to deal with hunger (n = 206, 55.8%). Weight loss programs by a dietitian were popular as individual appointments (n = 242, 65.1%) or an online program (n = 200, 53.5%). Nearly three-quarters of responders had or would use the internet to seek weight loss information (n = 308, 71.8%). Exercising was the most tried method of weight loss (n = 234, 71.1%). Most women had heard of IER (the “5:2 diet”) (n = 284, 73%) but only 34 had tried the diet. Of the women who hadn't heard of the 5:2 diet, 51.5% (n = 52) answered that it sounded like a good option and 15.8% (n = 16) didn't think the diet would suit them.

Conclusions

Despite most women reporting knowledge of their risk of T2DM, motivation to lose weight and family support, family responsibilities can make weight loss efforts difficult for mothers. Exercising, the 5:2 diet and use of the internet is an appealing option for some women however individual circumstances should be taken into consideration.

Funding Sources

The University of South Australia.

Bounce back- bounce forward: Midwifery students experience of resilience

Resilience is considered a vital characteristic and has gained attention in midwifery practice and education. In particular, midwifery students face challenges during their education in both academic and clinical components of the program. There is need for greater understanding and strategies to develop resilience in the midwifery student population. The aim of this study is to gain insight into how midwifery students conceptualise resilience, and explore how education might support the development of resilience. A focus group was conducted as part of a broader study underpinned by a concept analysis methodology to explore the students understanding of resilience. Participants included six third year midwifery students from one university. Thematic analysis was used to analyse the data. Four key themes were identified. Resilience contextualised to midwifery was triggered by exposure to adversity; resilience was identified as the ability to bounce back and move forward, and was seen to be important for midwifery students. The concept of resilience appears to play an important role in student success. Evidence suggests resilience can be developed and education providers have a role to foster student's resilience. Findings offer strategies to strengthen resilient behaviour for the midwifery student population and provide a basis for further research.

Exploring routine hospital antenatal care consultations - An ethnographic study

BACKGROUND

Listening to women as part of their antenatal care has been recognized as valuable in understanding the woman's needs. Conversations as part of routine antenatal interactions offer ideal opportunities for women to express themselves and for midwives to learn about the woman's issues and concerns. The antenatal visit and the convention of antenatal consultations for midwives have not been well explored or defined and much of what takes place replicate medical consultative processes. As a consequence, there is little to assist midwives construct woman-centred care consultations for their routine antenatal care practice. This study showed how some practices were better in promoting the woman's voice and woman-centred care in the hospital setting.

METHOD

Contemporary focused ethnography using both interview and observations, explored how midwives from six different public antenatal clinics in South Australia organized their antenatal care consultations with pregnant women.

FINDINGS

Thematic analysis of the data provided insights into professional interpretation of woman-centred practice. How midwives interacted with women during routine antenatal care events demonstrated that some practices in a hospital setting could either support or undermine a woman-centred philosophy.

CONCLUSION

Individual midwives adopted practices according to their own perceptions of actions and behaviors that were considered to be in accordance with the philosophy of woman-centred care. Information arising from this study has shown ways midwives may arrange antenatal care consultations to maximize women's participation.

It's more than just luck: A qualitative exploration of breastfeeding in rural Australia

It's more than just luck: A qualitative exploration of breastfeeding in rural Australia PROBLEM: Despite significant public health benefits, breastfeeding for six months continues to be challenging for women.

BACKGROUND

In the Mid North of South Australia, healthcare professionals were concerned that breastfeeding rates were lower than the national average and that a collaborative approach was needed to promote breastfeeding.

AIM

To explore the experiences of women and health professional in the Mid North, to inform interventions to improve breastfeeding longevity.

METHOD

Two focus groups were conducted to examine breastfeeding experience in the region. Focus group one included nine mothers who had breastfed more than six months and focus group two consisted of ten health professionals from the Mid North. Thematic analysis was used to analyse the data.

FINDINGS

Two overarching themes were identified; 'breastfeeding: It's more than just luck' represented the voices of the mothers and 'breastfeeding: It's everybody's business' captured the discussion between the health professionals. Women described themselves as lucky while acknowledging that their own persistence, as well as positive support was vital. Health professionals identified education and support as key foci, and a need for a holistic approach to improve breastfeeding rates.

DISCUSSION

Breastfeeding should be understood as a relationship, in which broadly applied solutions do not necessarily influence longevity, particularly in rural communities. Strategies should also reflect a realistic picture of breastfeeding and safeguard against idealistic expectation of the experience.

CONCLUSION

A holistic approach to improve breastfeeding rates is imperative. One of the most promising antidotes to the breastfeeding dilemma is the provision of midwifery continuity of care.

'Determined to breastfeed': A case study of exclusive breastfeeding using interpretative phenomenological analysis

BACKGROUND

Given the significant benefits of breastfeeding, the World Health Organization (WHO) recommend exclusive breastfeeding for six months. Despite numerous strategies aimed at increasing the percentage of babies who are exclusively breastfed, Australia currently has one of the lowest six-month exclusive breastfeeding rates in the developed world. Notably, most research focuses on the early postnatal period (birth-two months) yet the largest decline in exclusive breastfeeding rates is observed between two and six months.

AIM

This study aimed to understand what enabled a first-time mother to continue exclusively breastfeeding between two and six months in Australia.

METHODS

The qualitative approach known as interpretative phenomenological analysis (IPA) was used to explore how the new mother understood her exclusive breastfeeding journey. Data was collected retrospectively through a face-to-face, semi-structured interview, then transcribed in full and analyzed using IPA's approach to data analysis.

FINDINGS

Three main themes were identified as self-determination to achieve exclusive breastfeeding, the influence of social norms in Australian culture, and the impact social supports have on maintaining exclusive breastfeeding.

CONCLUSION

For this mother, her self-determination to exclusively breastfeed, along with positive social support, outweighed the impact of perceived social norms and negative pressure from significant others to stop exclusive breastfeeding. This qualitative reflection contributes to an understanding of the individual in the breastfeeding journey, uncovering nuances around exclusive breastfeeding that may be helpful in providing support for mothers and direction for further research.

We're all in this together: Midwifery student peer mentoring

Many higher education institutions have adopted mentoring programs for students as a means of providing support, improve learning and enhance the student experience. The aim of this project was to improve midwifery students experience by offering a peer mentoring program to commencing students to assist with the transition to university life and the rigours of the midwifery program. This paper reports the evaluation of this specific mentoring program and the ongoing development and implementation of a sustainable program within an Australian University. A survey design was adopted to gather feedback from both mentees to evaluate if the peer mentoring program enhanced the first year midwifery student experience and ascertain how the program could be further developed. Fifty-five students engaged with the peer mentors and completed the questionnaire regarding the mentoring program. Specifically valuable was the positive impact that mentoring had on midwifery student confidence, managing the demands of the program and being motivated to keep going when the program requirements were challenging. The success of this program rested largely with mentoring students sharing their own experiences and providing reassurance that other students could also succeed.

Assertiveness training for undergraduate midwifery students

Assertiveness can be defined as an interpersonal behaviour that promotes the fact all people in a relationship are equally important. All health professionals including midwives must work with and care for people. At times this will include facilitating interactions that require skilful negotiation and assertiveness. Yet embedding assertiveness education into undergraduate midwifery curricula has not been widely adopted. This paper explores one method of delivering assertiveness training in an undergraduate midwifery course and provides comment on the effectiveness of this strategy in developing assertiveness skills in a cohort of undergraduate midwifery students. We used an assertiveness survey which was administered immediately before and 3-4 months after an assertiveness training workshop. All students (n = 55) attending the training day were invited to participate. Of these 41 (77% response) chose to participate in the pre intervention survey and 32 participated (9 students lost to follow-up) in the follow up survey. There was an overall improvement in self-perceived assertiveness scores following the assertiveness training workshop. These findings provide encouraging evidence that educational institutions that offer specific and targeted assertiveness education will be rewarded with more assertive graduates.

Enhancing fathers' educational experiences during the early postnatal period

Since the 1970s, men have been encouraged to actively participate in the childbirth process, resulting in a shared experience for couples. Nevertheless, after the baby is born, many fathers find themselves displaced, unsure of how to embrace the transition to parenthood. The shift in cultural practice and evolving needs of families calls for the recognition of fathers as well as mothers in the provision of midwifery services. Innovative strategies must be considered to enhance postnatal education that is father-inclusive and responsive to the needs of families in the 21st century. This article introduces one strategy created from an action research study conducted to develop, implement, and evaluate strategies to improve postnatal education for parents.