The private journey: An interpretative phenomenological analysis of exclusive breastfeeding.

BACKGROUND: Exclusive breast milk provides complete nutrition for a baby's first six months of life. In Australia, breastfeeding initiation rates are high, however duration rates are low. Although numerous studies have explored the reasons behind low levels of breastfeeding, few have examined the experiences of women who maintain exclusive breastfeeding for the recommended six-month duration. AIM: This paper will present an in-depth, idiographic interpretation of first-time mothers' experience of exclusive breastfeeding for six months in Australia. METHOD: Interpretative phenomenological analysis was used to explore how five new mothers understood their six-month exclusive breastfeeding journey. Face-to-face, semi-structured interviews were conducted retrospectively, transcribed in full, and analysed using the flexible seven-step approach of interpretative phenomenological analysis. FINDINGS: Three higher-order themes were identified: (1) exclusive breastfeeding is a personal choice, (2) exclusive breastfeeding is harder than expected, and (3) everyone has something to say about breastfeeding. CONCLUSION: The mothers were not prepared for public debates around infant feeding methods, where mothers judge each other and give advice that supports their own goals, both of which create an unnecessary divide between mothers. Despite these issues, the findings highlight the personal and social meanings aligned with exclusive breastfeeding and point to the significance in fostering determination as a means to achieve exclusive breastfeeding goals. This qualitative reflection contributes a nuanced understanding of mothers' lived experience of exclusive breastfeeding, deepening our understanding and enabling appropriate strategies and support for the longevity of exclusive breastfeeding, as well as direction for continued 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 your body, but ' Mixed messages in childbirth education: Findings from a hospital ethnography.

OBJECTIVE: to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth. DESIGN: ethnography. SETTING: tertiary hospital in Australian city. PARTICIPANTS: sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork. FINDINGS: women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence. KEY CONCLUSIONS: informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices. IMPLICATIONS FOR PRACTICE: as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.

'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.

Paradox of the institution: findings from a hospital labour ward ethnography.

BACKGROUND: Interest in the influence of culture on birth practices is on the rise, and with it comes a sense of urgency to implement practices that aid the normalisation and humanisation of birth. This groundswell is occurring despite a broader cultural milieu of escalating technology-use and medicalisation of birth across the globe. Against this background, rates of epidural analgesia use by women in labour are increasing, despite the risk of side effects. Socio-cultural norms and beliefs are likely to influence pain relief choices but there is currently scant research on this topic. METHODS: This study was undertaken to gain insight into the personal, social, cultural and institutional influences on women in deciding whether or not to use epidural analgesia in labour. The study had an ethnographic approach within a theoretical framework of Critical Medical Anthropology (CMA), Foucauldian and feminist theory. Given the nature of ethnographic research, it was assumed that using the subject of epidural analgesia to gain insight into Western birth practices could illuminate broader cultural ideals and that the epidural itself may not remain the focus of the research. RESULTS: Findings from the study showed how institutional surveillance, symbolised by the Journey Board led to an institutional momentum that in its attempt to keep women safe actually introduced new areas of risk, a situation which we named the Paradox of the institution. CONCLUSIONS: These findings, showing a risk/safety paradox at the centre of institutionalised birth, add a qualitative dimension to the growing number of quantitative studies asserting that acute medical settings can be detrimental to normal birth practices and outcomes.

Influences on vaginal birth after caesarean section: A qualitative study of Taiwanese women.

BACKGROUND: Vaginal birth is a safe mode of birth for most women who have had a prior caesarean with a transverse incision. Despite the evidence, most Taiwanese women who have had a previous caesarean are rarely offered the opportunity to consider any possibility other than a repeat caesarean. AIM: This study explored factors affecting Taiwanese women's decisionmaking regarding vaginal birth after cesarean. METHODS: Ajzen's Theory of Planned Behaviour provided the theoretical framework to underpin the study, which adopted an interpretive descriptive methodology. Sequential semi-structured interviews were conducted with 29 women who had a previous caesarean and were pregnant between 34 and 38 weeks gestation, ten women who attempted vaginal birth in the third to fifth day postpartum, and 25 women in the fourth week postpartum. Boyatzis' method of thematic analysis was used to identify themes and codes. FINDINGS: This paper reports the findings of the prenatal interviews with 29 participants. The major factor influencing women's decision-making was to avoid negative outcomes for themselves and their babies. Three thematic codes describe influences on the women's decisions: 'past experience of childbirth', 'anticipating the next experience of normal birth' and 'contemplation on the process of childbirth'. CONCLUSIONS: Women who have had a previous caesarean section are prepared to have a vaginal birth but are not always supported to carry out this decision. Changing the models of antenatal care is recommended as a strategy to overcome this difficulty therefore empowering women to make a meaningful choice about VBAC after a CS.

Aboriginal and Torres Strait Islander women's experiences accessing standard hospital care for birth in South Australia - A phenomenological study.

BACKGROUND: Aboriginal and Torres Strait Islander women, hereafter called Indigenous women, can experience a lack of understanding of their cultural needs when accessing maternity care in the standard hospital care system. AIM: To explore the lived experiences described by Indigenous women accessing labour and birth care in the standard hospital care system at a tertiary public hospital in South Australia. METHODS: An interpretive Heideggerian phenomenological approach was used. Indigenous women who accessed standard care voluntarily agreed to participate in semi-structured interviews with Indigenous interviewers. The interviews were transcribed and analysed informed by van Manen's approach. FINDINGS: Thematic analysis revealed six main themes: "knowing what is best and wanting the best for my baby", "communicating my way", "how they made me feel", "all of my physical needs were met", "we have resilience and strength despite our hardships" and "recognising my culture". CONCLUSION: Indigenous women in this study expressed and shared some of their cultural needs, identifying culturally unsafe practices. Recommendations to address these include the extension of current care planners to include cultural needs; Aboriginal Maternal Infant Care (AMIC) workers for women from rural and remote areas; AMIC workers on call to assist the women and midwives; increased education, employment and retention of Indigenous midwives; increased review into the women's experiences; removal of signs on the door restricting visitors in the birth suite; flexibility in the application of hospital rules and regulations; and changes to birthing services in rural and remote areas so women may not have to relocate for birth.

Cultural safety and midwifery care for Aboriginal women - A phenomenological study.

BACKGROUND: Aboriginal and Torres Strait islander(1) women face considerable health disparity in relation to their maternity health outcomes when compared to non-Aboriginal women. Culture and culturally appropriate care can contribute to positive health outcomes for Aboriginal women. How midwives provide culturally appropriate care and how the care is experienced by the women is central to this study. AIM: To explore the lived experiences of midwives providing care in the standard hospital care system to Aboriginal women at a large tertiary teaching hospital. METHODS: An interpretive Heideggerian phenomenological approach was used. Semi-structured interviews were conducted with thirteen volunteer midwives which were transcribed, analysed and presented informed by van Manen's approach. FINDINGS: Thematic analysis revealed six main themes: "Finding ways to connect with the women", "building support networks - supporting with and through Aboriginal cultural knowledge", "managing the perceived barriers to effective care", "perceived equity is treating women the same", "understanding culture" and "assessing cultural needs - urban versus rural/remote Aboriginal cultural needs". CONCLUSION: The midwives in this study have shared their stories of caring for Aboriginal women. They have identified communication and building support with Aboriginal health workers and families as important. They have identified perceived barriers to the provision of care, and misunderstanding around the interpretation of cultural safety in practice was found. Suggestions are made to support midwives in their practice and improve the experiences for Aboriginal women.

Critical Medical Anthropology in Midwifery Research: A Framework for Ethnographic Analysis.

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

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour.

BACKGROUND: Approximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of 'normal' labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context. AIM: To examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth. METHODS: Ethnography, underpinned by a critical medical anthropology methodology. RESULTS: These findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence. CONCLUSIONS: As we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a 'risky' practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more 'dangerous' option.

Antenatal breast expression: exploration and extent of teaching practices amongst International Board Certified Lactation Consultant midwives across Australia.

BACKGROUND: Antenatal breast expression (ABE) has been taught in the past as breast preparation. Now some authorities are advising ABE and storage of colostrum for the feeding the newborn in the treatment and/or prevention of hypoglycaemia in the immediate postnatal period (thus avoiding the need for formula supplementation). The actual incidence of ABE teaching amongst International Board Certified Lactation Consultant (IBCLC) Midwives is unknown. Results of this study will provide valuable baseline data for future randomised controlled trials into this practice. RESEARCH QUESTION: What are the teaching practices surrounding ABE and the incidence of this type of teaching by IBCLC Midwives across Australia? METHOD: A descriptive cross-sectional Internet survey containing both quantitative and qualitative questions was sent to Australian IBCLC Midwives. Simple descriptive statistics was used to analyse quantitative data. Content analysis examined qualitative textual data of open-ended questions. FINDINGS: Response rate was 27% (n=347/1269). 93% (n=322) of those responding to the survey had heard of ABE. 60% (n=134) actively teach the practice. Descriptive statistics and content analysis revealed marked differences in teaching practices amongst this specialised group of midwives. CONCLUSION: This study suggested a large proportion of lactation qualified midwife respondents were aware of ABE and some currently teach the skill. However, advice given to women during pregnancy varied substantially.

Antenatal breast expression: a critical review of the literature.

OBJECTIVE: to critically review literature related to the practice of antenatal breast expression (ABE) and the reasons for this practice. METHOD: a critical review of available literature was undertaken by accessing Internet and library resources. Articles were to be documented in English. No restrictions were placed on dates due to the important historical background of this topic. Keywords used to refine the search included antenatal breast expression, colostrum, antenatal breast-feeding education and midwives and International Board Certified Lactation Consultants (IBCLC). FINDINGS: the literature search discovered ABE has been performed historically to prepare breasts for breast-feeding postnatally. It is presently being taught to store colostrum to prevent neonatal hypoglycaemia or hasten production of Lactogenesis 2. Studies relating to nipple stimulation were also critically appraised due to concerns of premature labour. CONCLUSIONS: the safety and efficacy of ABE has yet to be demonstrated. The three studies related to the benefits teaching of this skill were small in size with methodological flaws. Trials related to nipple stimulation were also found to have substantial limitations. The reasons for and physicality of performing ABE vs. nipple stimulation differed markedly. While recent teaching of ABE has been encouraged through available commentaries, case studies and policies (in view of the documented positive effects of early colostrum administration), the benefits of this practice are yet to be substantiated. IMPLICATIONS FOR PRACTICE: large, credible RCTs are needed to confirm efficacy and safety of this technique. A survey exploring the prevalence of ABE practices is also indicated and to explore the information currently provided by midwives to women in their care.

Actigraph estimates of the sleep of Australian midwives: the impact of shift work.

Midwives often work night and rotating shift schedules, which can lead to sleep disturbances, increased fatigue, and greater likelihood of accidents or errors. This study investigated the sleep of midwives (n = 17) in an Australian metropolitan hospital. Midwives completed work and sleep logbooks and wore wrist actigraphs for 28 days. Midwives worked combinations of morning, afternoon, and/or night shifts on constant (n = 6) or rotating schedules (n = 11). They obtained less than recommended amounts of sleep, getting only 6-7 hr per 24-hr period. Morning shifts were associated with the lowest sleep durations, lowest subjective sleep quality, and highest postsleep fatigue ratings. Despite the significantly higher amount of wake after sleep onset (51 min), the sleep before afternoon shifts had significantly lower postsleep fatigue ratings and was rated as significantly higher quality than sleep before other shifts or days off. Those who were married or living with a partner reported significantly more sleep and lower postsleep fatigue than those who were separated or divorced (p < .05). Seventy-one percent of midwives took naps, primarily before night shifts, with nearly 40% of nightshifts preceded by a nap. Average nap durations were nearly 1.5 hr. Midwives reported feeling moderately to very physically or mentally exhausted on 22-50% of all shifts and days off. Exhaustion was most common on night shift. This study suggests that midwives may be suffering from chronic sleep loss and as a consequence may be at risk of impairments in functioning that accompany fatigue.

Sleep, stress and compensatory behaviors in Australian nurses and midwives / Sono, estresse e comportamentos compensatórios por enfermeiras e parteiras australianas / Sueño, estrés y comportamientos compensatorios por enfermeras y parteras australianas

OBJECTIVE: To describe sleep, stress and compensatory behaviors in nurses and midwives. METHODS: The study included 41 midwives and 21 nurses working in Australian hospitals between 2005 and 2009. Participation was voluntary. All participants recorded on a daily basis their work and sleep hours, levels of stress and exhaustion, caffeine intake and use of sleep aids for a month (1,736 days, 1,002 work shifts). RESULTS: Participants reported moderate to high levels of stress and exhaustion on 20-40 percent of work days; experienced sleep disruption on more than 50 percent of work days; struggled to remain awake on 27 percent of work days; and suffered extreme drowsiness or experienced a near accident while travelling home on 9 percent of workdays. Age, perceived sleep duration and work hours were significant predictors of caffeine intake. About 60 percent of participants reported using sleep aids (about 20 percent reported taking prescription medications and 44 percent of nurses and 9 percent of midwives reported alcohol use as a sleep aid at least once during the study). Stress and workdays were significant predictors of sedative use. Overall, 22 percent reported being indifferent or mildly dissatisfied with their job. CONCLUSIONS: Sleep problems, high levels of stress and exhaustion and low job satisfaction are prevalent among nurses and midwives. The use of alcohol and sleeping pills as sleep aids, and the use of caffeine to help maintain alertness is also common. Nurses and midwives may use caffeine to compensate for reduced sleep, especially on workdays, and sleeping pills to cope with their daily work-related stress.

OBJETIVO: Descrever sono, estresse e comportamentos compensatórios em enfermeiras e parteiras. MÉTODOS: O estudo incluiu 41 enfermeiras 21 parteiras em hospitais australianos de 2005 a 2009. A participação foi voluntária. Os participantes registraram diariamente as horas de trabalho, sono, stress e níveis de exaustão, cafeína e uso de ajuda para dormir durante um mês (1.736 dias, 1.002 turnos). RESULTADOS: Os participantes relataram de moderados a elevados níveis de stress e de exaustão em 20 por cento-40 por cento dos dias de trabalho; experimentaram distúrbios do sono em mais de 50 por cento dos dias de trabalho; relataram esforço para permanecer acordado em 27 por cento dos dias de trabalho; e sofreram sonolência extrema ou acidente perto de casa em 9 por cento dos dias de trabalho. Idade, duração do sono percebida e jornadas foram preditores significativos da ingestão de cafeína. Aproximadamente 60 por cento dos participantes relataram utilizar a ajuda para dormir: cerca de 20 por cento relataram uso de medicação prescrita e 44 por cento das enfermeiras e 9 por cento das parteiras consumiam álcool como auxílio para dormir pelo menos uma vez durante o estudo. Estresse e dias de trabalho foram preditores significativos do uso de sedativos. Em geral, 22 por cento relataram ser indiferente, ou ligeiramente insatisfeito com seu trabalho. CONCLUSÕES: Problemas no sono, estresse e exaustão elevados e diminuição na satisfação no trabalho são prevalentes. São comuns o uso de álcool e de medicamentos para dormir, e consumo de cafeína para se manter alerta. Enfermeiras e parteiras parecem usar a cafeína para compensar a redução do sono, especialmente em dias de trabalho, e usar soníferos para compensar o estresse diário.

OBJETIVO: Describir sueño, estrés y comportamientos compensatorios en enfermeras y parteras. MÉTODOS: El estudio incluyó 41 enfermeras 21 parteras en hospitales australianos de 2005 a 2009. La participación fue voluntaria. Los participantes registraron diariamente las horas de trabajo, sueño, estrés y niveles de agotamiento, cafeína y uso de ayuda para dormir durante un mes (1.736 días, 1.002 turnos). RESULTADOS: Los participantes relataron de moderados a elevados niveles de estrés y de agotamiento en 20 por ciento-40 por ciento de los días de trabajo; experimentaron disturbios del sueño en más de 50 por ciento de los días de trabajo; relataron esfuerzo para permanecer despierto en 27 por ciento de los días de trabajo; y sofrieron somnolencia extrema o accidente cerca de casa en 9 por ciento de los días de trabajo. Edad, duración del sueño percibido y jornadas fueron predictores significativos de la ingestión de cafeína. Aproximadamente 60 por ciento de los participantes relataron utilizar la ayuda para dormir: cerca de 20 por ciento usaron de medicación prescripta y 44 por ciento de las enfermeras y 9 por ciento de las parteras consumirán alcohol como auxilio para dormir al menos una vez durante el estudio. Estrés y días de trabajo fueron predictores significativos del uso de sedativos. En general, 22 por ciento relataron ser indiferente, o ligeramente insatisfecho con su trabajo. CONCLUSIONES: Problemas en el sueño, estrés y agotamiento elevados y disminución en la satisfacción en el trabajo son prevalecientes. Uso de alcohol y de medicamentos para dormir, y consumo de cafeína para mantenerse alerta también es común. Enfermeras y parteras pueden usar la cafeína para compensar la reducción del sueño, especialmente en días de trabajo, y usar somníferos para compensar el estrés diario.

Sleep, stress and compensatory behaviors in Australian nurses and midwives.

OBJECTIVE: To describe sleep, stress and compensatory behaviors in nurses and midwives. METHODS: The study included 41 midwives and 21 nurses working in Australian hospitals between 2005 and 2009. Participation was voluntary. All participants recorded on a daily basis their work and sleep hours, levels of stress and exhaustion, caffeine intake and use of sleep aids for a month (1,736 days, 1,002 work shifts). RESULTS: Participants reported moderate to high levels of stress and exhaustion on 20-40% of work days; experienced sleep disruption on more than 50% of work days; struggled to remain awake on 27% of work days; and suffered extreme drowsiness or experienced a near accident while travelling home on 9% of workdays. Age, perceived sleep duration and work hours were significant predictors of caffeine intake. About 60% of participants reported using sleep aids (about 20% reported taking prescription medications and 44% of nurses and 9% of midwives reported alcohol use as a sleep aid at least once during the study). Stress and workdays were significant predictors of sedative use. Overall, 22% reported being indifferent or mildly dissatisfied with their job. CONCLUSIONS: Sleep problems, high levels of stress and exhaustion and low job satisfaction are prevalent among nurses and midwives. The use of alcohol and sleeping pills as sleep aids, and the use of caffeine to help maintain alertness is also common. Nurses and midwives may use caffeine to compensate for reduced sleep, especially on workdays, and sleeping pills to cope with their daily work-related stress.

Improving the professional support for parents of young infants.

The objective of this study was to discuss ideas for improving child health services on the basis of findings of an observational study that was designed to explore the role of child health nurses in supporting parents during the first 6 months following the birth of an infant. As part of a larger study in a child health service in urban Australia, surveys were used to collect data from two independent samples of both parents and nurses at an 8-month interval. Data were condensed using factor analysis; regression analyses were used to determine which aspects of care were most important for the parents, and importance-performance analysis was used to determine which aspects of care needed improvement. While the majority of parents valued support from child health nurses, a need for improvement was identified in empowering parents to make their own decisions, discussing emotional issues with parents, providing continuity of care and giving consistent advice. Organisations should value and provide support for child health nurses in their invisible, non-quantifiable work of supporting families. The structure of child health services should also provide child health nurses continuity of care with the families they support.

An examination of maternity staff attitudes towards implementing Baby Friendly Health Initiative (BFHI) accreditation in Australia.

BACKGROUND: The Baby Friendly Hospital Initiative (BFHI) influences health care practices and increases the initiation and duration of exclusive breastfeeding. Consistent definitions enable the accurate monitoring of breastfeeding rates and behaviour. This information refines policy and helps reach national breastfeeding targets. Only 21% (66/317) of Australian hospitals are BFHI accredited. OBJECTIVE: To examine the factors perceived to promote or hinder BFHI accreditation. METHOD: Focus group interviews explored opinions of 31 participants, in differing roles and levels of employment, across midwifery, medical, nursing and ancillary staff at six South Australian maternity hospitals. RESULTS: The results suggest that staffs' understanding and personal views are often discordant with BFHI aims. Perceived difficulties include the accreditation process, hospital dynamics, and the Ten Steps implementation plus a bottle feeding culture and maternal employment that impact upon continued breastfeeding. CONCLUSIONS: Upper management support, specific funding, a dedicated co-ordinator with "area leaders", development of a specific breastfeeding policy incorporating various disciplines and staff, containing detailed protocols that comply with the International Code of Marketing of Breast Milk Substitutes and subsequent World Health Assembly (WHA) resolutions, are all required. Staff and mothers require multiple modes of education to understand the BFHI, including sponsorship for training of lactation consultants. Full implementation of BFHI across Australia will assist the development of nationally accepted breastfeeding definitions, improve monitoring and evaluation of rates and practices, and improve breastfeeding outcomes.

The role of child health nurses in supporting parents of young infants.

OBJECTIVE: As a part of an action research project to determine a model of service to meet the needs of parents, this non-experimental study explored the role of child health nurses in supporting parents of young infants. It also examined whether changes to the service altered parents' views of that support. METHODS: Two surveys were conducted at eight month interval during which changes had been implemented in the child health service. The participants, recruited from well child health clinics, comprised 413 parents of infants younger than 12 months of age (206 in the first survey and 207 in the second survey). Data were collected by self-report questionnaires developed for the study, and analysed using descriptive and inferential statistics, factor analysis and linear regression. RESULTS: The results showed the majority of parents (n = 328, 79%) had valued the professional support from child health nurses, but there was no significant difference between the two surveys in the parents' views of overall support they had received. Although parents reported improvement in accessibility and availability of the services, no improvement had occurred in the aspects of care most important for them. These were to be respected as a parent, have their parenting skills validated and be supported to make their own infant care choices. CONCLUSION: Empowering parents to make their own decisions about infant care is imperative for child health nurses in order for them to support parents effectively. The child health nurses need to build the parents' capacity to make their own decisions through giving relevant information about care options and supporting parents in their decisions.

Mood change and perception of workload in Australian midwives.

Investigations of mood and workload in health care settings have focussed primarily on nurses and junior doctors. Given the critical shortfall in the Australian midwifery workforce, and the specialised nature of midwifery as an occupation, it is important to understand how mood and workload are experienced by midwives. Twenty midwives (18F, 2M) in an Australian metropolitan hospital completed logbooks assessing daily fluctuations in subjective mood and workload. Participants also provided information about history of psychopathology and sleep quality. Results revealed that midwives were relatively stable in terms of mood but did experience increased fear and decreased happiness when at work. Further, workload factors significantly predicted mood at work. Specifically, when participants felt that their work was more demanding and frustrating and required more effort, or when they felt that they could not accomplish all that was expected, mood was negatively influenced. This supports the connection between workload and negative mood change in healthcare. Given the potential for mood to influence a multitude of functions relevant to safety, performance and psychosocial wellbeing it is important to understand the factors which influence mood, particularly in light of the current shortfall in the Australian healthcare workforce.

Understanding the emerging relationship between complementary medicine and mainstream health care: a review of the literature.

The history of the relationship between complementary medicine (CM) and mainstream health care has shifted from the early days of pluralism, through hostility and exclusion, to one of grudging acceptance. The current situation is one of a tacit acknowledgement and in some cases open endorsement by biomedicine for a number of forms of CM practice, largely driven by the popularity of CM to consumers in our increasingly market driven health care system. How this relationship is ultimately worked out will impact both on the practice of CM and biomedicine, and on the health care choices available to consumers. In this article we review the research and commentary literature on the current and emerging relationship between biomedicine and CM. In particular we explore the ways in which mainstream inclusion of CM is discussed in the literature, and the biomedical and CM perspectives of mainstream CM inclusion. Finally we discuss the implications of the emerging relationship for CM, and CM practitioners and consumers.