The profile of women who consult midwives in Australia.

BACKGROUND: There is no Australian data on the characteristics of women who consult with midwives. AIM: To determine the profile of women who consult midwives in Australia. METHODS: This cross-sectional research was conducted as part of the Australian Longitudinal Study on Women's Health (ALSWH). Participants were the younger (31-36 years) cohort of the ALSWH who completed a survey in 2009, and indicated that they were currently pregnant (n=801). The main outcome measure was consultation with a midwife. FINDINGS: Of the 801 women who indicated that they were currently pregnant at the time of the survey, 19%, 42%, and 70% of women in the first, second and third trimesters respectively had consulted with a midwife. Women were more likely to consult a midwife if they: also consulted with a hospital doctor (OR=2.70, 95% CI: 1.66, 4.40); also consulted with a complementary and alternative medicine practitioner (OR=1.94, 95% CI: 1.25, 3.03); were depressed (OR=1.84, 95% CI: 1.03, 3.28); constipated (OR=1.80, 95% CI: 1.04, 3.13); or had been diagnosed or treated for hypertension during pregnancy (OR=2.78, 95% CI: 1.27, 6.09). Women were less likely (OR=0.34, 95% CI: 0.21, 0.56) to consult with a midwife if they had private health insurance. CONCLUSION: Women were more likely to consult with midwives in conjunction with consultations with hospital doctors or complementary and alternative medicine practitioners. Women with private health insurance were less likely to consult midwives. More research is necessary to determine the implications of the lack of midwifery care for these women.

Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years.

OBJECTIVE: To report maternal and neonatal outcomes for Australian women planning a publicly funded homebirth from 2005 to 2010. DESIGN, SETTING AND SUBJECTS: Retrospective analysis of data on women who planned a homebirth and on their babies. Data for 2005-2010 (or from the commencement of a program to 2010) were requested from the 12 publicly funded homebirth programs in place at the time. MAIN OUTCOME MEASURES: Maternal outcomes (mortality; place and mode of birth; perineal trauma; type of management of the third stage of labour; postpartum haemorrhage; transfer to hospital); and neonatal outcomes (early mortality; Apgar score at 5 minutes; birthweight; breastfeeding initially and at 6 weeks; significant morbidity; transfer to hospital; admission to a special care nursery). RESULTS: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%. CONCLUSION: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia.

Group versus conventional antenatal care for women.

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 is through a group model. OBJECTIVES: The first objective was to compare the effects of group antenatal care versus one-to-one care on outcomes for women and their babies. The primary outcomes were preterm birth (birth occurring before 37 completed gestational weeks), low birthweight (less than 2500 g), small-for-gestational age (less than the tenth percentile for gestation and gender) and perinatal mortality. Secondary outcomes included psychological measures and satisfaction as well as labour and birth and postnatal outcomes.The second objective was to compare the effects of group care versus one-to-one care on care provider satisfaction. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 March 2012), 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 for inclusion but none were identified. Cross-over trials were not eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and evaluated trial quality. Two authors extracted data. Data were checked for accuracy. MAIN RESULTS: We included two studies (1369 women). There were no statistically significant differences between women who received group antenatal care compared with standard one-to-one care in relation to the primary outcomes. In particular, there was no difference in the rate of preterm birth rate between the two groups (risk ratio (RR) 0.87; 95% confidence interval (CI) 0.47 to 1.60; two trials; N = 1315) and the proportion of low birthweight (less than 2500 g) babies was similar between the groups (RR 1.03; 95% CI 0.73 to 1.46; two trials; N = 1315).Satisfaction was rated highly in women who were allocated to group antenatal care but only measured in one trial. In this trial, the mean satisfaction with care in group antenatal care was almost five times higher compared with those allocated to standard care (N = 993). A number of outcomes related to stress, distress and depression were reported in one trial. There were no differences between the groups in any of these outcomes.There were no data available on the effects of group antenatal care on care provider satisfaction. AUTHORS' CONCLUSIONS: The available evidence suggests that group antenatal care is positively viewed by women with no adverse outcomes for themselves or their babies. This review is limited owing to the small number of studies/women and the majority of the analyses are based on a single study. More research is required to determine if group antenatal care is associated with significant benefits.

Safe timing for an urgent Caesarean section: what is the evidence to guide policy?

OBJECTIVE: To determine, from the evidence, what is the optimum decision to delivery (DDI) intervals in emergency Caesarean sections (CS). The aim of the study was to help guide policy in maternity services and identify issues relating to DDI and safe practice in maternity care. METHOD: A systematic review of the literature was undertaken. Assessment of the quality of eligible papers was undertaken using the Critical Appraisal Skills Program (CASP) rating. RESULTS: There is no strong evidence that a DDI of 30 min or less is associated with improved outcomes for babies or mothers. Some evidence suggests that a DDI of greater than 30 min but less than 75 min confers benefit, but these findings were confounded by the indications for the emergency CS. CONCLUSION: Urgent CS should occur as soon as possible, but there is insufficient evidence to support a definite time frame, such as 30 min. A consistency of approach and nomenclature in describing the urgency of CS is necessary, which would enable criteria for further audit regarding DDI. Staff training should be addressed to improve transfer systems for CS. Antenatal risk assessment and congruence with role delineation and service delivery capacity is important.

'It's more than just having a baby' women's experiences of a maternity service for Australian Aboriginal and Torres Strait Islander families.

OBJECTIVE: the Malabar Community Midwifery Link Service was developed to meet the needs of women from Aboriginal and Torres Strait Islander communities in suburban Sydney, Australia. This paper reports the evaluation from the perspective of the Aboriginal and Torres Strait Islander women who accessed the service. METHODS: a descriptive study using quantitative and qualitative approaches was undertaken for the first two years of the service. Clinical outcomes for women who gave birth in 2007 and 2008 were collected prospectively. A focus group with Aboriginal and Torres Strait Islander women was conducted, then tape recorded, transcribed verbatim and analysed qualitatively. FINDINGS: 353 women gave birth through the Malabar service during 2007 and 2008. Over 40% of the babies born were identified as Aboriginal and Torres Strait Islander. Almost all the women had their first antenatal visit before 20 weeks of pregnancy. The service was successful in reducing the number of women smoking cigarettes during pregnancy. Women felt the service provided ease of access, continuity of care and caregiver, trust and trusting relationships. CONCLUSIONS: the Malabar service is an excellent example of a primary health care model of care that is meeting the needs of the community. Improving maternal and neonatal outcomes takes considerable time as the underlying causes of the disparities are complex. IMPLICATIONS: further research into ways to ensure that services like Malabar can address issues like smoking in pregnancy and the range of social and emotional issues faced by Australian Aboriginal and Torres Strait Islander women and families needs to be undertaken. More community-based appropriate services should be developed for these families.

Publicly-funded homebirth models in Australia.

BACKGROUND: Publicly-funded homebirth programs in Australia have been developed in the past decade mostly in isolation from each other and with limited published evaluations. There is also distinct lack of publicly available information about the development and characteristics of these programs. We instigated the National Publicly-funded Homebirth Consortium and conducted a preliminary survey of publicly-funded homebirth providers. AIM: To outline the development of publicly-funded homebirth models in Australia. METHODS: Providers of publicly-funded homebirth programs in Australia were surveyed using an on-line survey in December 2010. Questions were about their development, use of policy and general operational issues. A descriptive analysis of the quantitative data and content analysis of the qualitative data was undertaken. FINDINGS: In total, 12 programs were identified and 10 contributed data to this paper. The service providers reported extensive multidisciplinary consultation and careful planning during development. There was a lack of consistency in data collection throughout the publicly-funded homebirth programs due to different databases, definitions and the use of different guidelines. DISCUSSION: Publicly-funded homebirth services followed different routes during their development, but essentially had safety and collaboration with stakeholders, including women and obstetricians, as central to their process. CONCLUSION: The National Publicly-funded Homebirth Consortium has facilitated a sharing of resources, processes of development and a linkage of homebirth services around the country. This analysis has provided information to assist future planning and developments in models of midwifery care. It is important that births of women booked to these programs are clearly identified when their data is incorporated into existing perinatal datasets.

Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review.

AIM: The aim of this study was to review non-clinical interventions that increase the uptake and/or the success rates of vaginal birth after caesarean section. BACKGROUND: Increases in rates of caesarean section are largely due to repeat caesarean section in a subsequent pregnancy. Concerns about vaginal birth after caesarean section have centred on the risk of uterine rupture. Nonetheless, efforts to increase the vaginal birth rate in these women have been made. This study reviews these in relation to non-clinical interventions. DATA SOURCES: Literature was searched up until December 2008 from five databases and a number of relevant professional websites. REVIEW METHODS: A systematic review of quantitative studies that evaluated a non-clinical intervention for increasing the uptake and/or the success of vaginal birth after caesarean section was undertaken. Only study designs that involved a comparison group were included. Further exclusions were imposed for quality using the Critical Skills Appraisal Programme. RESULTS: National guidelines influence vaginal birth after caesarean section rates, but a greater effect is seen when institutions develop local guidelines, adopt a conservative approach to caesarean section, use opinion leaders, give individualized information to women, and give feedback to obstetricians about mode of birth rates. Individual clinician characteristics may impact on the number of women choosing and succeeding in vaginal birth after caesarean section. There is inconsistent evidence that having private health insurance may be a barrier to the uptake and success of vaginal birth after caesarean section. CONCLUSION: Non-clinical factors can have a significant impact on vaginal birth after caesarean section uptake and success.

Clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review.

AIM: The aim of this study was to review clinical interventions that increase the uptake and/or the success rates of vaginal birth after caesarean section. BACKGROUND: Repeat caesarean section is the main reason for the increase in surgical births. The risk of uterine rupture in women who have prior caesarean sections prevents many clinicians from recommending vaginal birth after caesarean. Despite this, support for vaginal birth after caesarean continues. DATA SOURCES: A search of five databases and a number of relevant professional websites was undertaken up to December 2008. REVIEW METHODS: A systematic review of quantitative studies that involved a comparison group and examined a clinical intervention for increasing the uptake and/or the success of vaginal birth after caesarean section was undertaken. An assessment of quality was made using the Critical Skills Appraisal Programme. RESULTS: Induction of labour using artificial rupture of membranes, prostaglandins, oxytocin infusion or a combination, was associated with lower vaginal birth rates. Cervical ripening agents such as prostaglandins and transcervical catheters may result in lower vaginal birth rates compared with spontaneous labour. The impact of epidural anaesthesia in labour on vaginal birth after caesarean success is inconclusive. X-ray pelvimetry is associated with reduced uptake of vaginal birth after caesarean and higher caesarean section rates. Scoring systems to predict likelihood of vaginal birth are largely unhelpful. There is insufficient data in relation to vaginal birth after caesarean section between different closure methods for the primary caesarean section. CONCLUSION: Clinical factors can affect vaginal birth after caesarean uptake and success.

Maternal mortality in Australia: learning from maternal cardiac arrest.

Cardiac arrest in pregnancy is fortunately a rare event that few midwives will see during their career. The increase in maternal age, the Body Mass Index, cesarean sections, multiple pregnancies, and comorbidities over recent years have increased the probability of cardiac arrest. The early warning signs of impending maternal cardiac arrest are either absent or go unrecognized. Maternal mortality reviews highlight the deficiencies that maternity care providers have in managing cardiac arrest in pregnancy.The aim of this article is to address the knowledge deficiencies of health professionals by reviewing the physiological changes in pregnant women that complicate the management of cardiopulmonary resuscitation, using a case scenario. There are key differences in the management of pregnant women, when compared to standard adult resuscitation.The outcome is dependent on the speed of the response and the consideration of a number of crucial pregnancy-specific interventions. Staff members need to be adequately trained in order to deal with maternal cardiac arrest and have access to training packages and in-service education programs. As cardiac arrest in pregnancy is a rare event, emergency drill simulations are an important component of ongoing education.

Multiparous women's confidence to have a publicly-funded homebirth: a qualitative study.

BACKGROUND: Hospital birth is commonly thought to be a safer option than homebirth, despite many studies showing similar rates of safety for low risk mothers and babies when cared for by qualified midwives with systems of back-up in place. Recently in Australia, demand has led to the introduction of a small number of publicly-funded homebirth programs. Women's confidence in having a homebirth through a publicly-funded homebirth program in Australia has not yet been explored. AIM: The aim of the study was to explore the reasons why multiparous women feel confident to have a homebirth within a publicly-funded model of care in Australia. METHODS: Ten multiparous English-speaking women who chose to have a homebirth with the St George Hospital Homebirth Program were interviewed in the postnatal period using semi-structured, open-ended questions. Interviews were transcribed, then a thematic analysis was undertaken. RESULTS: Women, having already experienced a normal birth, demonstrated a strong confidence in their ability to give birth at home and described a confidence in their bodies, their midwives, and the health system. Women weighed up the risks of homebirth through information they gathered and integration with their previous experience of birth, their family support and self-confidence. DISCUSSION: Women choosing publicly-funded homebirth display strong confidence in both themselves to give birth at home, and their belief in the health system's ability to cope with any complications that may arise. IMPLICATIONS FOR PRACTICE: Many women may benefit from access to publicly-funded homebirth models of care. This should be further investigated.

Examining the content validity of the birthing unit design spatial evaluation tool within a woman-centered framework.

INTRODUCTION: The environment for birth influences women in labor. Optimal birthing environments have the potential to facilitate normal labor and birth. The measurement of optimal birth units is currently not possible because there are no tools. An audit tool, the Birth Unit Design Spatial Evaluation Tool (BUDSET), was developed to assess the optimality of birthing environments. The BUDSET is based on 4 domains (fear cascade, facility, aesthetics, support), each comprising design principles that are further differentiated into specific assessable design items. In the process of developing measurement tools, content validity must be established. The aim of this study was to establish the content validity of the BUDSET from the perspective of women and midwives. METHODS: This was a mixed-methods study with a survey assessing agreement with BUDSET items and in-depth interviews. Survey results were analyzed using an item-level content validity index and a survey-level validity index. Interview data were analyzed using a directed content analysis approach. The study was conducted in 2 locations-a major maternity hospital and a midwifery research center, both in Australia. Study participants were 10 women and 2 midwifery academics. RESULTS: The survey revealed that content-related validity varied according to the BUDSET domain, with the domains of facility and support established as content valid by most participants. The domains of the fear cascade and aesthetic were less strong, particularly among pregnant women. Interview data analysis provided content validity evidence of both the fear cascade and aesthetic domains. A further 4 subthemes of fear cascade also were identified: foreign space, medical-hospital-emergency, being sterile/clinical, and protecting the woman from the environment. Content validity evidence for facility and support domains also was established. DISCUSSION: This study has established that the BUDSET is content valid for assessing the optimality of birthing environments. Some further refinement of the tool is now possible.

Staffing, skill mix and the model of care.

AIMS AND OBJECTIVES: The study aimed to explore whether nurse staffing, experience and skill mix influenced the model of nursing care in medical-surgical wards. BACKGROUND: Methods of allocating nurses to patients are typically divided into four types: primary nursing, patient allocation, task assignment and team nursing. Research findings are varied in regard to the relationship between these models of care and outcomes such as satisfaction and quality. Skill mix has been associated with various models, with implications for collegial support, teamwork and patient outcomes. DESIGN: Secondary analysis of data collected on 80 randomly selected medical-surgical wards in 19 public hospitals in New South Wales, Australia during 2004-2005. METHODS: Nurses (n = 2278, 80.9% response rate) were surveyed using The Nursing Care Delivery System and the Nursing Work Index-Revised. Staffing and skill mix was obtained from the ward roster and other data from the patient record. Models of care were examined in relation to these practice environment and organisational variables. RESULTS: The models of nursing care most frequently reported by nurses in medical-surgical wards in this study were patient allocation (91%) and team nursing (80%). Primary nursing and task based models were unlikely to be practised. Skill mix, nurse experience, nursing workload and factors in the ward environment significantly influenced the model of care in use. Wards with a higher ratio of degree qualified, experienced registered nurses, working on their 'usual' ward were more likely to practice patient allocation while wards with greater variability in staffing levels and skill mix were more likely to practice team nursing. CONCLUSIONS: Models of care are not prescriptive but are varied according to ward circumstances and staffing levels based on complex clinical decision making skills. RELEVANCE TO CLINICAL PRACTICE: Variability in the models of care reported by ward nurses indicates that nurses adapt the model of nursing care on a daily or shift basis, according to patients' needs, skill mix and individual ward environments.

Violence toward nurses, the work environment, and patient outcomes.

PURPOSE: To relate nurses' self-rated perceptions of violence (emotional abuse, threat, or actual violence) on medical-surgical units to the nursing working environment and to patient outcomes. DESIGN: Cross-sectional collection of data by surveys and primary data collection for 1-week periods on 94 nursing wards in 21 hospitals in two states of Australia. METHODS: Nursing Work Index-Revised (NWI-R); Environmental Complexity Scale (ECS) PRN-80 (a measure of patient acuity); and a nursing survey with three questions on workplace violence; combined with primary data collection for staffing, skill mix, and patient outcomes (falls, medication errors). FINDINGS: About one third of nurses participating (N=2,487, 80.3% response rate) perceived emotional abuse during the last five shifts worked. Reports of threats (14%) or actual violence (20%) were lower, but there was great variation among nursing units with some unit rates as high as 65%. Reported violence was associated with increased ward instability (lack of leadership; difficult MD and RN relationships). Violence was associated with unit operations: unanticipated changes in patient mix; proportion of patients awaiting placement; the discrepancy between nursing resources required from acuity measurement and those supplied; more tasks delayed; and increases in medication errors. Higher skill mix (percentage of registered nurses) and percentage of nurses with a bachelor of science in nursing degrees were associated with fewer reported perceptions of violence at the ward level. Intent to leave the present position was associated with perceptions of emotional violence but not with threat or actual assault. CONCLUSIONS: Violence is a fact of working life for nurses. Perceptions of violence were related to adverse patient outcomes through unstable or negative qualities of the working environment. Perceptions of violence affect job satisfaction. CLINICAL RELEVANCE: In order to manage effectively the delivery of nursing care in hospitals, it is essential to understand the complexity of the nursing work environment, including the relationship of violence to patient outcomes.

Advanced nursing practice: a global perspective.

AIM: To review the titles, roles and scope of practice of Advanced Practice Nurses internationally. BACKGROUND: There is a worldwide shortage of nurses but there is also an increased demand for nurses with enhanced skills who can manage a more diverse, complex and acutely ill patient population than ever before. As a result, a variety of nurses in advanced practice positions has evolved around the world. The differences in nomenclature have led to confusion over the roles, scope of practice and professional boundaries of nurses in an international context. METHOD: CINAHL, Medline, and the Cochrane database of Systematic Reviews were searched from 1987 to 2008. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant. FINDINGS: There are many names for Advanced Practice Nurses, and although many of these roles are similar in their function, they can often have different titles. CONCLUSION: Advanced Practice Nurses are critical for the future, provide cost-effective care and are highly regarded by patients/clients. They will be a constant and permanent feature of future health care provision. However, clarification regarding their classification and regulation is necessary in some countries.

Implications of staff 'churn' for nurse managers, staff, and patients.

In this article, the term "churn" is used not only because of the degree of change to staffing, but also because some of the reasons for staff movement are not classified as voluntary turnover. The difficulties for the nurse managing a unit with the degree of "churn" should not be under-estimated. Changes to skill mix and the proportions of full-time, agency, and temporary staff present challenges in providing clinical leadership, scheduling staff, performance management, and supervision. Perhaps more importantly, it is likely that there is an impact on the continuity of care provided in the absence of continuity of staffing. A greater understanding of the human and financial costs and consequences, and a willingness to change established practices at the institutional and ward level, are needed.

Staff satisfaction and retention and the role of the nursing unit manager.

Despite recent increases in nursing recruitment in Australia, participation in the workforce is still below the numbers predicted to meet future needs. This paper discusses factors impacting on nurses' job satisfaction, satisfaction with nursing and intention to leave in public sector hospitals in New South Wales (NSW), Australia. Staffing and patient data were collected on 80 medical and surgical units during 2004/5. This included a wide range of individual nurse data from a Nurse Survey; detailed and comprehensive staffing data including skill mix variables; patient characteristics; workload data; a profile of the ward's characteristics; and adverse event patient data. Nurses who were intending to remain in their job were more likely to be satisfied, be older, and have dependents. They were also likely to be experiencing good leadership and to have allied health support on the ward. Most nurses reported being satisfied with their profession, while a lower proportion reported satisfaction with their current position. Work environment factors such as nurses' autonomy, control over their practice and nursing leadership on the ward were statistically significant predictors of job satisfaction. This study will inform decision-making and policy for managers in both the public and private hospital sectors. This is the first large study which explored the work environment at the ward/unit level in public hospitals in NSW (Australia). It illustrates that there are no typical wards; each ward functions differently. The importance of nursing leadership at the ward level to job satisfaction, satisfaction with nursing and intention to leave, cannot be overstated.

The St. George Homebirth Program: an evaluation of the first 100 booked women.

BACKGROUND: The St. George Homebirth Program was the first publicly funded homebirth model of care set up in New South Wales. This program provides access to selected women at low obstetric risk the option of having their babies at home. There are only four other publicly funded homebirth programs operating in Australia. AIMS: To report the outcomes of the first 100 women booked at the St. George Homebirth Program. METHODS: A prospective descriptive study was undertaken. Data were collected on the first 100 women who gave birth between November 2005 and March 2009. Two databases were accessed and missing data were followed up by review of the relevant charts. RESULTS: Of the first 100 booked women, 63 achieved a homebirth, 30 were transferred to hospital or independent midwifery care in the antenatal period and seven were transferred intrapartum. Two women were transferred to hospital in the early postnatal period, one for a postpartum haemorrhage and one for hypotension. One baby suffered mild respiratory distress, was treated in the emergency department and was discharged home within four hours. CONCLUSION: The St. George Hospital homebirth program has provided reassuring outcomes for the first 100 women it has cared for over the past four years. Wider availability of this service could be achieved provided there is the appropriate close collaboration between providers and effective processes for consultation, referral and transfer. The outcomes of women and babies in publicly funded homebirth programs deserve further study, and the development of a national prospective database of all planned homebirth would contribute to this knowledge.

Vitamin D, PTH and calcium levels in pregnant women and their neonates.

OBJECTIVES: To determine the prevalence of vitamin D deficiency in pregnant women and their neonates and to examine factors associated with vitamin D deficiency. DESIGN AND PATIENTS: Population-based study of pregnant women and their neonates from South-eastern Sydney, Australia. MEASUREMENTS: Serum 25 hydroxy-vitamin D (25-OHD), PTH, calcium, albumin, phosphate and alkaline phosphatase were measured in women at 23-32 weeks gestation and on cord blood at delivery. Maternal skin phototype was recorded using the Fitzpatrick scale. RESULTS: Vitamin D deficiency (defined as 25-OHD