What strategies facilitate & support the successful transition of newly qualified midwives into practice: An integrative literature review.

OBJECTIVE: The aim of this review was to identify strategies that facilitate newly qualified midwives to transition successfully from midwifery student to confident, competent practitioner. DESIGN: Integrative literature review. DATA SOURCES: The following databases were accessed: CINAHL complete, Medline complete, APA PsycINFO, Cochrane Library, Joanna Briggs Institute (JBI), Scopus and Google Scholar. REVIEW METHODS: A systematic search of key terms across all data sources for the period January 1990 to September 2021 identified 316 papers whose titles/abstracts were screened against our inclusion/exclusion criteria. Thirty-six full texts were screened for eligibility and three papers were identified through ancestral searching. Ten papers were included in our final review. RESULTS: Mentorship or preceptorship for newly qualified midwives by experienced midwives appears to enhance experiences, either as a standalone strategy, or component of structured programs of transition support. Supernumerary time, designated study days and planned rotations are also valued, particularly when rotating through clinical areas. Smaller teams providing continuity of midwifery care, or organisations that fund mentorship programs appear more able to facilitate support. Mechanisms of online support and learning may also enhance early transition but similarly, require organisational investment to aid success. Whilst most programs were described as helpful none of the studies used validated measures to assess this. CONCLUSION: Whilst elements of tailored support programs and mentoring/preceptorship from experienced colleagues appear to offer valuable support to transitioning practitioners, it is important to note that the structure of maternity care appears fundamental to the success of many of these strategies. Consequently, maternity care reform which focuses on the adoption of sustainable models of midwifery continuity, alongside urgent investment in midwives, are likely the most promising, over-arching strategies required to support student to midwife transition.

Midwifery and nursing students' perceptions of respectful maternity care and witnessing of disrespect and abuse: A comparative study from Nepal and Jordan.

OBJECTIVES: To compare Nepalese and Jordanian midwifery and nursing students' perceptions of respectful maternity care (RMC) and witnessing of disrespect and abuse; and determine factors that predict scores on a scale measuring perceptions of RMC. DESIGN: A descriptive, comparative design was used. SETTING: Recruitment took place from two medical colleges in Nepal and one University in Jordan. METHODS: A convenience sample of students (n = 276) enrolled in a Bachelor or Diploma level midwifery or nursing degree who were undertaking or had recently completed their midwifery clinical placement were recruited. The online or hard copy survey included the Students' Perceptions of Respectful Maternity Care (SPRMC) Scale and nine questions on witnessing different types of disrespect and abuse. FINDINGS: Nepalese students were slightly older (mean = 23.68 years) than Jordanian students (mean = 21.36). Mean duration of clinical placement was longer for Jordanian students (11.24 compared to 6.28 weeks). However, mean number of births observed was higher among Nepalese students (19.6 compared to 18.62). Overall, perceptions of RMC were more positive among Jordanian students (t (199.97) = 6.68, p < 0.001). A multiple regression analysis found that duration of clinical placement (beta = 0.22, p < 0.001), witnessing disrespect and abuse (beta = 0.11, p = 0.08) and age (beta = -0.14, p = 0.03) explained 12.2% of variance in SPMRC scores. Compared to students in Nepal, all Jordanian students had observed non-consented care during their clinical practicum. However, Nepalese students were more likely to observe poor adherence to women's privacy and confidentiality. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: This is the first study to compare midwifery and nursing students' perceptions of RMC across two middle-income countries. Although Jordanian students held more positive perceptions of RMC than those in Nepal, more had witnessed different forms of disrespect and abuse. Variations in students' perceptions of RMC and witnessing of abuse across countries highlight the need for assessment of workplace cultures to inform the development of tailored education and practice interventions for students, clinicians, and managers. Future research needs to explore how to best support students to consistently offer RMC and how to improve the experiences of childbearing women.

Effectiveness of an online education intervention to enhance student perceptions of Respectful Maternity Care: A quasi-experimental study.

BACKGROUND: Childbearing women's relationship with maternity care providers enhance childbirth outcomes. Students need to understand and offer respectful care. OBJECTIVE: Evaluate effectiveness and impact of an online education intervention on nursing students' perceptions towards respectful maternity care during labour and childbirth in Nepal. DESIGN: A quasi-experimental pre-post design was used. PARTICIPANTS: A total of 89 Third Year Bachelor of Nursing students (intervention n = 40; control n = 49) from three participating colleges. METHODS: Students completed online pre and post-test surveys using the Students' Perceptions of Respectful Maternity Care scale and questions about impact of the intervention. The intervention group received six hours of education delivered online (three sessions x three weeks). ANCOVA and non-parametric Wilcoxon signed-rank tests measured effects. RESULTS: Compared to controls, students in the intervention group reported a significant increase in perceptions towards respectful maternity care (F (1, 86) = 28.19, p < 0.001, ηp2 = 0.25). Participants reported a good understanding of respectful maternity care (75%), positive views about providing such care (82.5%), and a desire to use their new knowledge in practice (65%). CONCLUSION: Relatively few intervention studies to promote respectful maternity care in students have been published. This brief online intervention improved students' perceptions. The intervention package can be integrated into nursing or midwifery curricula and in-service training. A larger study with longer follow-up is needed to support current findings.

Educational interventions to promote respectful maternity care: A mixed-methods systematic review.

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

Midwives providing woman-centred care during the COVID-19 pandemic in Australia: A national qualitative study.

BACKGROUND: The COVID-19 pandemic has caused isolation, fear, and impacted on maternal healthcare provision. AIM: To explore midwives' experiences about how COVID-19 impacted their ability to provide woman-centred care, and what lessons they have learnt as a result of the mandated government and hospital restrictions (such as social distancing) during the care of the woman and her family. METHODS: A qualitative interpretive descriptive study was conducted. Twenty-six midwives working in all models of care in all states and territories of Australia were recruited through social media, and selected using a maximum variation sampling approach. Data were collected through in-depth interviews between May to August, 2020. The interviews were recorded, transcribed verbatim, and thematically analysed. FINDINGS: Two overarching themes were identified: 'COVID-19 causing chaos' and 'keeping the woman at the centre of care'. The 'COVID-19 causing chaos' theme included three sub-themes: 'quickly evolving situation', 'challenging to provide care', and 'affecting women and families'. The 'Keeping the woman at the centre of care' theme included three sub-themes: 'trying to keep it normal', 'bending the rules and pushing the boundaries', and 'quality time for the woman, baby, and family unit'. CONCLUSION: Findings of this study offer important evidence regarding the impact of the pandemic on the provision of woman-centred care which is key to midwifery philosophy. Recommendations are made for ways to preserve and further enhance woman-centred care during periods of uncertainty such as during a pandemic or other health crises.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era.

BACKGROUND: COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers. METHODS: A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers. RESULTS: If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births. CONCLUSIONS: Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

Normalisation process theory as a conceptual framework for continuity of carer implementation.

PROBLEM: Despite long standing strategic level ambitions to increase access to continuity of carer (CoC) models in maternity services, implementation of CoC in the United Kingdom (UK) has been generally small-scale and short lived. This indicates problems in implementing and sustaining CoC as the main model of care provision, and as such a need to better understand the process of implementation itself. AIM: To use normalisation process theory (NPT) to underpin development of a conceptual implementation framework for CoC in order to improve understanding of the implementation process. METHODS: Literature review on CoC implementation and NPT development and use, combined with immersion in the implementation of CoC context. RESULTS AND DISCUSSION: A conceptual framework for the implementation of CoC is developed and individual components discussed, with a view to better understanding the implementation process for CoC models. The will of a critical mass of midwives to work in a CoC model and the provision and maintenance of the 'organisational space' required for CoC within the National Health Service (NHS) emerge as key barriers to mainstreaming CoC in the UK. CONCLUSION: There is utility in NPT as a means of understanding and conceptualising large scale implementation of CoC. With testing and further development into a practical tool, the conceptual framework developed here could become a useful aid to those involved in implementing and evaluating CoC in the context of renewed strategic direction and Governmental level support in the UK.

Implementing continuity of midwife carer - just a friendly face? A realist evaluation.

BACKGROUND: Good quality midwifery care saves the lives of women and babies. Continuity of midwife carer (CMC), a key component of good quality midwifery care, results in better clinical outcomes, higher care satisfaction and enhanced caregiver experience. However, CMC uptake has tended to be small scale or transient. We used realist evaluation in one Scottish health board to explore implementation of CMC as part of the Scottish Government 2017 maternity plan. METHODS: Participatory research, quality improvement and iterative data collection methods were used to collect data from a range of sources including facilitated team meetings, local and national meetings, quality improvement and service evaluation surveys, audits, interviews and published literature. Data analysis developed context-mechanism-outcome configurations to explore and inform three initial programme theories, which were refined into an overarching theory of what works for whom and in what context. RESULTS: Trusting relationships across all organisational levels are the context in which CMC works. However, building these relationships during implementation requires good leadership and effective change management to drive whole system change and foster trust across all practice and organisational boundaries. Trusting relationships between midwives and women were valued and triggered a commitment to provide high quality care; CMC team relationships supported improvements in ways of working and sustained practice, and relationships between midwives and providers in different care models either sustained or constrained implementation. Continuity enabled midwives to work to full skillset and across women's care journey, which in turn changed their perspective of how they provided care and of women's care needs. In addition to building positive relationships, visible and supportive leadership encourages engagement by ensuring midwives feel safe, valued and informed. CONCLUSION: Leadership that builds trusting relationships across all practice and organisational boundaries develops the context for successful implementation of CMC. These relationships then become the context that enables CMC to grow and flourish. Trusting relationships, working to full skill set and across women's care journey trigger changes in midwifery practice. Implementing and sustaining CMC within NHS organisational settings requires significant reconfiguration of services at all levels, which requires effective leadership and cannot rely solely on ground-up change.

Midwives' views of changing to a Continuity of Midwifery Care (CMC) model in Scotland: A baseline survey.

BACKGROUND: There is good evidence that Continuity of Midwifery Care (CMC) is associated with improved clinical outcomes, greater maternal satisfaction, and improved work experiences for midwives. Changes made to the organisation require careful implementation, with on-going evaluation to monitor progress. AIM: To develop a survey tool that incorporates several validated scales, which was used to collect baseline data prior to implementing a high-quality Continuity of Midwifery Care (CMC) model in Scotland (Hewitt et al., 2019). This tool gathered data about midwives' personal and professional wellbeing prior to service reorganisation, with a longitudinal study intended to measure change in midwives' reportage across time. This paper reports the baseline data-collection. METHODS: An on-line survey was shared with practising midwives (n=321) in Scotland via the NHS intranet, verbally, email, and paper. The survey elicited midwives views about Continuity of Midwifery Care (CMC); values and philosophies of care; attitudes towards their professional role; personal and professional demographics; quality of life and wellbeing. Psychometric attitudinal scales were scored and free text comments themed according to positive/negative opinions of the new Continuity of Midwifery Care (CMC) model to highlight key concerns to be addressed and identify change barriers or facilitators. FINDINGS: The majority of midwives indicated support for philosophies underpinning Continuity of Midwifery Care (CMC), which includes physiological birth and providing autonomous midwifery care. Participants also indicated positive attitudes towards their current role and organisation, with some worrying about how the organisation was going to implement the changes required. Worries included, receiving an overburdening workload, being deskilled in certain areas of midwifery practice, and lack of support were litigation to arise. CONCLUSION: Midwives support the values and philosophies that underpin Continuity of Midwifery Care (CMC), yet worry about organisational change involved in evolving systems of care. Hence, management require to implement strategies to reduce fears. For example, delivering accurate and honest information, enabling midwives to plan, design and implement changes themselves, and providing emotional and material help.

Women's views about a free breast pump service: Online survey informing intervention development.

Improving breastfeeding outcomes is a global priority; however, in the United Kingdom, continuation of breastfeeding remains low. Growing empirical evidence suggests a free breast pump service might be an acceptable and feasible incentive intervention to improve breastfeeding outcomes and reduce heath inequalities. To inform intervention development, we conducted an online survey with women recruited via social media using snowball sampling. Data were analysed descriptively (closed questions) with qualitative thematic analysis (free text). The survey was completed by 666 women, most of whom had recently breastfed and used a breast pump. Participants agreed that free pump hire (rental/loan; 567 women; 85.1%) or a free pump to keep (408; 61.3%) should be provided. Free text comments provided by 408 women (free pump) and 309 women (free hire) highlighted potential benefits: helping women to continue breastfeeding; express milk; overcome difficulties; and pump choice. Concerns are possible effect on breast milk supply, reduced breastfeeding, pumps replacing good support for breastfeeding, and pump hire hygiene. Personal and societal costs are important issues. Some suggested a pump service should be for low-income mothers, those with feeding difficulties or sick/preterm infants. A one-size service would not suit all and vouchers were proposed. Some suggested fees and deposits to prevent waste. To our knowledge, this is the first study reporting views about the acceptability of providing a free breast pump hire service. Mothers support and wish to have a say in breast pump service development. Future evaluations should address impact on feeding outcomes, professional support, hygiene for hired pumps, and costs.

Midwifery continuity of carer: Developing a realist evaluation framework to evaluate the implementation of strategic change in Scotland.

Midwifery continuity of carer (MCC) models result in better clinical outcomes for women and offer midwives a superior way of working when compared to other models of maternity care. Implementing a MCC model, a key recommendation of the Scottish Government Maternity and Neonatal Strategy Best Start, requires significant restructuring of maternity services and changes to midwives' roles. Careful evaluation is therefore required to monitor and understand how the policy affects care providers and users. Realist evaluation is an appropriate methodology for evaluating programmes of change set within complex social organisations, such as health services, and can help to understand variations in outcomes and experiences. This paper presents the approach taken using the principles of realist evaluation to identify key programme theories, which then informed an evaluation framework and a midwives' evaluation tool. The comprehensive survey-tool developed for midwives has the potential to be used more widely to evaluate comparable strategic change in this area.

The Effect of the More Active MuMs in Stirling Trial on Body Composition and Psychological Well-Being among Postnatal Women.

Introduction. Physical activity is important for health and well-being; however, rates of postnatal physical activity can be low. This paper reports the secondary outcomes of a trial aimed at increasing physical activity among postnatal women. Methods. More Active MuMs in Stirling (MAMMiS) was a randomised controlled trial testing the effect of physical activity consultation and pram walking group intervention among inactive postnatal women. Data were collected on postnatal weight, body composition, general well-being, and fatigue. Participants were also interviewed regarding motivations and perceived benefits of participating in the trial. Results. There was no significant effect of the intervention on any weight/body composition outcome or on general well-being at three or six months of follow-up. There was a significant but inconsistent difference in fatigue between groups. Qualitative data highlighted a number of perceived benefits to weight, body composition, and particularly well-being (including improved fatigue) which were not borne out by objective data. Discussion. The MAMMiS study found no impact of the physical activity intervention on body composition and psychological well-being and indicates that further research is required to identify successful approaches to increase physical activity and improve health and well-being among postnatal women.

Antenatal physical activity: a qualitative study exploring women's experiences and the acceptability of antenatal walking groups.

BACKGROUND: Regular physical activity (PA) can be beneficial to pregnant women, however, many women do not adhere to current PA guidelines during the antenatal period. Patient and public involvement is essential when designing antenatal PA interventions in order to uncover the reasons for non-adherence and non-engagement with the behaviour, as well as determining what type of intervention would be acceptable. The aim of this research was to explore women's experiences of PA during a recent pregnancy, understand the barriers and determinants of antenatal PA and explore the acceptability of antenatal walking groups for further development. METHODS: Seven focus groups were undertaken with women who had given birth within the past five years. Focus groups were transcribed and analysed using a grounded theory approach. Relevant and related behaviour change techniques (BCTs), which could be applied to future interventions, were identified using the BCT taxonomy. RESULTS: Women's opinions and experiences of PA during pregnancy were categorised into biological/physical (including tiredness and morning sickness), psychological (fear of harm to baby and self-confidence) and social/environmental issues (including access to facilities). Although antenatal walking groups did not appear popular, women identified some factors which could encourage attendance (e.g. childcare provision) and some which could discourage attendance (e.g. walking being boring). It was clear that the personality of the walk leader would be extremely important in encouraging women to join a walking group and keep attending. Behaviour change technique categories identified as potential intervention components included social support and comparison of outcomes (e.g. considering pros and cons of behaviour). CONCLUSIONS: Women's experiences and views provided a range of considerations for future intervention development, including provision of childcare, involvement of a fun and engaging leader and a range of activities rather than just walking. These experiences and views relate closely to the Health Action Process Model which, along with BCTs, could be used to develop future interventions. The findings of this study emphasise the importance of involving the target population in intervention development and present the theoretical foundation for building an antenatal PA intervention to encourage women to be physically active throughout their pregnancies.

Efficacy of physical activity interventions in post-natal populations: systematic review, meta-analysis and content coding of behaviour change techniques.

This systematic review and meta-analysis reports the efficacy of post-natal physical activity change interventions with content coding of behaviour change techniques (BCTs). Electronic databases (MEDLINE, CINAHL and PsychINFO) were searched for interventions published from January 1980 to July 2013. Inclusion criteria were: (i) interventions including ≥1 BCT designed to change physical activity behaviour, (ii) studies reporting ≥1 physical activity outcome, (iii) interventions commencing later than four weeks after childbirth and (iv) studies including participants who had given birth within the last year. Controlled trials were included in the meta-analysis. Interventions were coded using the 40-item Coventry, Aberdeen & London - Refined (CALO-RE) taxonomy of BCTs and study quality assessment was conducted using Cochrane criteria. Twenty studies were included in the review (meta-analysis: n = 14). Seven were interventions conducted with healthy inactive post-natal women. Nine were post-natal weight management studies. Two studies included women with post-natal depression. Two studies focused on improving general well-being. Studies in healthy populations but not for weight management successfully changed physical activity. Interventions increased frequency but not volume of physical activity or walking behaviour. Efficacious interventions always included the BCTs 'goal setting (behaviour)' and 'prompt self-monitoring of behaviour'.

How UK internet websites portray breast milk expression and breast pumps: a qualitative study of content.

BACKGROUND: Exclusive breastfeeding for six months is recommended but few parents achieve this; particularly younger and less well-educated mothers. Many parents introduce infant formula milk to manage feeding but describe a desire to express breastmilk alongside a lack of support or information. The Internet is highlighted as a key resource. This study aimed to examine UK websites on expressing breastmilk to identify key messages and how information is provided. METHODS: We used search terms in Google to identify websites with information rich content on expressing breastmilk and breast pumps. Ten sites were purposively selected at two time points in 2013 and 2014 to represent 3 categories: commercial, NHS or 3(rd) sector (voluntary or not for profit). Each site was reviewed by two researchers, data and reflective analytical notes were uploaded into NVivo and thematic data analysis undertaken. RESULTS: Sites varied considerably in their design, use of images, videos, audio files, product placement and marketing opportunities. Three key themes emerged: depiction of expressing; reasons to express; and recommendations about expressing. Inconsistent and conflicting information was common within and between sites. Expressing was portrayed as similar to, but easier than, breastfeeding although at the same time difficult and requiring to be learned. Expressed breastmilk is promoted by mainly commercial sites as immediately available, although pumps were also presented as needing to be concealed, not heard or seen. Health benefits were the overarching reason for expressing. Although predicated on separation from the baby, commercial sites identified this as a positive choice while other sites focused on separation due to circumstance. Commercial sites emphasised restrictions related to breastfeeding, lack of sleep and bonding with the father and wider family. Non-commercial sites emphasised hand expression, with some not mentioning breast pumps. Practical information about starting expressing in relation to infant age or duration of breastfeeding was conflicting. CONCLUSIONS: Internet information about expressing breastmilk is inconsistent, incomplete and not evidence informed. The lack of research evidence on the relationship between expressing and feeding outcomes has provided opportunities for commercial companies, which have the potential to further exacerbate observed health inequalities. Access to good quality information based on robust evidence is urgently required.

Significant others, situations and infant feeding behaviour change processes: a serial qualitative interview study.

BACKGROUND: Exclusive breastfeeding until six months followed by the introduction of solids and continued breastfeeding is recommended by the World Health Organisation. The dominant approach to achieving this has been to educate and support women to start and continue breastfeeding rather than understanding behaviour change processes from a broader perspective. METHOD: Serial qualitative interviews examined the influences of significant others on women's feeding behaviour. Thirty-six women and 37 nominated significant others participated in 220 interviews, conducted approximately four weekly from late pregnancy to six months after birth. Responses to summative structured questions at the end of each interview asking about significant influences on feeding decisions were compared and contrasted with formative semi-structured data within and between cases. Analysis focused on pivotal points where behaviour changed from exclusive breastfeeding to introducing formula, stopping breastfeeding or introducing solids. This enabled us to identify processes that decelerate or accelerate behaviour change and understand resolution processes afterwards. RESULTS: The dominant goal motivating behaviour change was family wellbeing, rather than exclusive breastfeeding. Rather than one type of significant other emerging as the key influence, there was a complex interplay between the self-baby dyad, significant others, situations and personal or vicarious feeding history. Following behaviour change women turned to those most likely to confirm or resolve their decisions and maintain their confidence as mothers. CONCLUSIONS: Applying ecological models of behaviour would enable health service organisation, practice, policy and research to focus on enhancing family efficacy and wellbeing, improving family-centred communication and increasing opportunities for health professionals to be a constructive influence around pivotal points when feeding behaviour changes. A paradigm shift is recommended away from the dominant approach of support and education of individual women towards a more holistic, family-centred narrative approach, whilst acknowledging that breastfeeding is a practical skill that women and babies have to learn.

Developing maternal self-efficacy for feeding preterm babies in the neonatal unit.

Developing maternal self-efficacy offsets negative psychological consequences of premature birth, improving maternal well-being. We investigated women's experiences in a neonatal unit (NNU) in Scotland in semistructured interviews with 19 primiparous mothers of preterm babies. We explored their experience of preterm birth and development of self-efficacy in infant feeding behaviors, identifying emergent and a priori themes. Women reported experiencing loss and biographical disruption in relation to mothering, loss of autonomy, and searching for normality after premature birth. Providing breast milk symbolized embodied contact with their baby and increased maternal confidence. They developed motivation, knowledge, and perseverance and perceived success from positive feedback, primarily from their baby and health professionals' support and encouragement. Women actively constructed opportunities to develop ownership, control, and confidence in relation to interactions with their baby. We linked sources of self-efficacy with potential behavior change techniques to be used in practice to improve maternal confidence in the NNU.

More Active Mums in Stirling (MAMMiS): a physical activity intervention for postnatal women. Study protocol for a randomized controlled trial.

BACKGROUND: Many postnatal women are insufficiently physically active in the year after childbirth and could benefit from interventions to increase activity levels. However, there is limited information about the efficacy, feasibility and acceptability of motivational and behavioral interventions promoting postnatal physical activity in the UK. METHODS: The MAMMiS study is a randomized, controlled trial, conducted within a large National Health Service (NHS) region in Scotland. Up to 76 postnatal women will be recruited to test the impact of two physical activity consultations and a 10-week group pram-walking program on physical activity behavior change. The intervention uses evidence-based motivational and behavioral techniques and will be systematically evaluated using objective measures (accelerometers) at three months, with a maintenance measure taken at a six-month follow-up. Secondary health and well-being measures and psychological mediators of physical activity change are included. DISCUSSION: The (MAMMiS study will provide a test of a theoretical and evidence-based physical activity behavior change intervention for postnatal women and provide information to inform future intervention development and testing within this population. TRIAL REGISTRATION: Current Controlled Trials ISRCTN79011784.

Exploring cognitive skill development in midwifery education.

Changes in maternity services and the role of the midwife mean that the midwife must provide flexible, evidence-based, woman-centred care. As the lead professional, the midwife must use a high level of professional judgement, clinical reasoning and decision-making to enable choice while ensuring the safety and wellbeing of mother and infant. Delayed development of these cognitive skills is suggested by the continuing theory-practice gap, suboptimal practice and students requiring to conform to non-evidence-based practice. The purpose of this research was to explore midwifery students' understanding and experience of the development of cognitive skills. The research employed analysis of undergraduate midwifery programme documentation and a focus group discussion with student midwives from second and third year of the programme. Document analysis and thematic analysis of the interview data indicated a lack of emphasis on cognitive skill development and a sense that these skills improve naturally through exposure to clinical practice. The findings suggest a need to change our approach to learning in clinical practice and to conduct further research to improve understanding of mechanisms to support the development of cognitive skills.

What future for midwifery?

Safe, effective and high quality maternity care is crucial to the wellbeing of mother and baby and for society as a whole. The midwife is now recognized and recommended as the lead professional and co-ordinator of care for low risk women and plays a central role in ensuring a safe outcome for mother and newborn. A number of key policy documents, service audits and reviews highlight the essential role of the midwife and the skills and expertise required to provide expert care and make educated decisions about care management. Yet there has been considerable attention and debate in the media, from the public and from the profession itself because of the current shortage of midwives in England. This paper debates some of the implications of the lack of midwives and the need to ensure a commitment to the recruitment and education of midwives who are equipped to deal with the challenges of providing the highest quality woman-centred care which is safe, effective and meets the changing needs of society and the profession. Some of the questions centre around the importance of the availability of midwives to provide midwifery care and support the development of student midwives, as well as the need to ensure continued access to opportunities to maintain and update midwives' knowledge and skills.