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Tertiary level midwifery educational pathways to achieve registration as a midwife vary in Australia, with a shift from the hospital to the university sector more than 20 years ago. These pathways are often referred to in the workforce setting to distinguish midwives with different academic backgrounds.To discuss the genesis of midwifery education in the Australian setting and explore the impact of the language used to describe the educational backgrounds on the professional identity of midwives.Strong tertiary and regulatory governance exists to support the robust development of midwifery educational programmes and to ensure a high-quality, woman-centred workforce. Once registered, all midwives have the same skill set to provide care to women and families. However, separatist language is often used to describe midwives according to their educational background which has a propensity to reduce positive midwifery identity and influence continuing workforce attrition rates.Positive expression of midwifery identity, using a strength discourse and an inclusive workforce have the ability to strengthen job satisfaction and intention to remain in the profession. Midwifery education can occur through several pathways; however once registered, all midwives are equal.

Problem Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. Background Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. Aim To explore Australian midwives experience and consequences of moral distress. Methods Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. Findings Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. Discussion It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. Conclusion This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

BackgroundIn Australia, the provision of maternity care during the COVID-19 pandemic was significantly altered to limit transmission of the virus. Many hospitals limited face-to-face appointments to only the pregnant woman and restricted the number of support people present during labour, birth, and postnatal visits to one person. How these restrictions were experienced by partners and support persons of childbearing women are unknown.AimTo explore the experiences of partners and support persons of women receiving maternity care during the COVID-19 pandemic.MethodsA two-phased qualitative study including an online survey and interviews. Analysis was undertaken using content analysis.FindingsPartners and support persons experienced a sense of 'missing out' from the pregnancy and maternity care experience because of changes in the provision of care during the pandemic. They reported feelings of isolation, psychological distress, and reduced bonding time with babies. Conflicting information and processes within and across maternity services contributed to feelings of uncertainty and a perceived reduction in the quality of care. Partners and support persons were negatively impacted by restrictions on maternity wards, however they also perceived these to be of benefit to women.DiscussionMany partners and support persons were negatively impacted by restrictions in maternity services during the pandemic; strategies to ensure their active involvement in maternity care are needed.ConclusionThis study offers insights from the unique perspective of partners and support people of women receiving maternity care during the pandemic. Policies and processes that exclude partners and support persons need to be reconsidered.

Problem The COVID-19 pandemic has required rapid and radical changes to the way maternity care is provided in many nations across the world. Background Midwives provide care to childbearing women across the continuum and are key members of the maternity workforce in Australia. Aim To explore and describe midwives’ experiences of providing maternity care during the COVID-19 pandemic in Australia. Methods A two-phased cross-sectional descriptive study was conducted. Data were collected through an online survey and semi-structured interviews between May-June 2020. Findings Six hundred and twenty midwives responded to the online survey. Many reported a move to telehealth appointments. For labour care, 70% of midwives reported women had limited support; 77% indicated postnatal visiting was impacted. Five main themes were derived from the qualitative data including: coping with rapid and radical changes, challenges to woman-centred care, managing professional resilience, addressing personal and professional challenges, and looking ahead. Discussion Restrictions applied to women’s choices, impacted midwives’ ability to provide woman-centred care, which resulted in stress and anxiety for midwives. Professional resilience was supported through collaborative relationships and working in continuity models. Midwives revealed ‘silver linings’ experienced in providing care during the pandemic. Conclusion Findings provide valuable evidence to understand the impact on midwives who have provided care during the COVID-19 pandemic. Knowledge will be useful for health leaders and policy makers as they consider ways to continue care during the pandemic and support the essential midwifery workforce. Recommendations are presented to improve preparedness for future pandemics.

Background High infant mortality remains a global health problem, particularly in less developed countries. Indonesia has one of the highest infant mortality rates in Southeast Asia. Known factors relate to documented medical conditions and do not necessarily explain their origin. Aim To identify and explore factors that contribute to infant mortality in Papua, Indonesia, through the lens of health workers’ perceptions. Methods A qualitative descriptive approach using semi-structured interviews was used. Twelve Indonesian health workers participated. Interviews were audio-recorded and transcribed, and then analysed thematically. Findings Five main themes were generated: beliefs and practices related to pregnancy, birth, and infants; infant health factors; maternal health factors; barriers to seeking, receiving and providing infant health care; and enablers and strategies for improving infant health. Discussion Cultural factors were perceived as contributing to poor health outcomes by shaping decisions, help seeking behaviour and health care access. Poverty, health literacy, road access and transport, shortage of health staffing, and health equipment and medicines exacerbate poor health outcomes. Conclusion Cultural knowledge and sensitivity are central to the provision and acceptance of health care by local families in Papua, Indonesia. Recommendations include: improving cultural sensitivity and cultural safety of service; implementing community health promotion to enhance maternal and infant health; improving community participation in health care planning and delivery; and enhancing collaboration between national, provincial, regency and local governments.

Background In 2010, the Nursing and Midwifery Board of Australia introduced a new registration standard: Endorsement for scheduled medicines for midwives. The endorsement enables midwives to provide women with Medicare-rebatable care, prescribe relevant medications, and order relevant Medicare-rebatable diagnostics. Translating endorsement education into clinical midwifery practice has been slow, indicating the presence of barriers affecting midwives’ ability to use this standard, despite it increasing their scope for service provision. Aim To discover the mechanisms affecting midwives’ ability to work to full scope of practice after completing a programme of study leading to endorsement. Methods An observational (non-experimental) design was used. Midwives who had completed an education programme leading to endorsement were invited to complete a survey. Descriptive statistics were used to analyse the quantitative questions and content analysis was conducted on the qualitative data. Findings Results indicated that barriers – such as the limitations of Medicare provisions for endorsed midwives and a general lack of support for the role – restrict endorsed midwives’ ability to provide quality maternity services. Having some form of support for the role may act as an enabler, in addition to midwives having personal determination and confidence in their ability to use the endorsement. Recommendations to strengthen the endorsed midwife's role include facilitating endorsement use in the public sector, relaxing Medicare Benefit Schedule and Pharmaceutical Benefit Scheme restrictions, raising awareness of the role and scope, and improving midwives’ pre-endorsement preparation. Conclusion This study highlights the need for an all-of-system approach to support and develop the endorsed midwife's role.

Background The Australian Midwifery Standards Assessment Tool (AMSAT) was developed against the Competency Standards for the Midwife in 2017 to enable consistent assessment of midwifery student performance in practice-based settings. The AMSAT requires revision and re-validation as the competency standards have now been superseded by the Midwife Standards for Practice 2018. Objective This research revised and validated the AMSAT to assess performance of midwifery students against the Midwife Standards for Practice 2018 and assessed its sensitivity. Design A mixed-methods approach was used in a two-phase process. Phase one involved the re-wording of the AMSAT and behavioural cue statements in an iterative participatory process with midwifery academics, assessors and students. The tool was field-tested in different assessment environments in phase two. Completed assessment forms were statistically analyzed, whilst assessor surveys were analysed using descriptive statistics and qualitative content analysis. Findings Analysis of AMSAT (n = 255) indicates the tool as: internally reliable (Cronbach alpha > .9); valid (eigenvalue of 16.6 explaining 67% of variance); and sensitive (score analysis indicating increased levels of proficiency with progressive student experience). Analysis of surveys (n = 108) found acceptance of the tool for the purpose of summative and formative assessment, and in the provision of feedback to midwifery students on their performance. Conclusion This study demonstrates that the re-developed AMSAT is a valid, reliable and acceptable tool to assess midwifery students’ performance against the Australian Midwife Standards for Practice This user-friendly tool can be used to standardize midwifery student assessment in Australia and enable continued benchmarking across education programs.

Background Reflective practice is a core professional competency and the hallmark of an autonomous, evidence-based midwife practitioner committed to lifelong learning. Despite this professional imperative little is currently known about how the development of reflective capacity is facilitated with midwifery students. Aim This study aimed to determine (1) the extent to which a holistic, structured model of reflection develops reflective capacity in midwifery students; and (2) their perceptions of learning and teaching strategies that build reflective capacity. Design A qualitative cross-sectional design involving focus groups and thematic analysis. Participants The Bass Model of Holistic Reflection was introduced to promote development of reflective capacity in midwifery students enrolled in entry to practice programs in two Australian universities. Students were provided with guidance on how to apply the model to their reflections. After using the model for at least one trimester twenty-seven (27) participants volunteered to participate in focus groups. Findings Four themes emerged ‘safe space within a circle of trust’, ‘deep personal learning’, ‘consistency of application by skilled facilitators’, and ‘integration and connection’. Key conclusions and implications for practice Use of a holistic model combined with integrative and structured reflective activities supports the scaffolded and developmental nature of reflection. Alignment of the model with a woman centred midwifery philosophy generates midwifery knowledge and reflects student expectations of their role as aspiring midwives. Midwives’ attitudes regarding reflection influences students’ perceptions of value. Quality of feedback provided by educators affects levels of student motivation and engagement with reflection.

Problem There are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia’s Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use. Objective To critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement. Method A search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria. Findings Although singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers. Conclusion Barriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual’s support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement’s use in midwifery.

Background Practice-based or clinical placements are highly valued for linking theory to practice and enabling students to meet graduate outcomes and industry standards. Post-practicum, the period immediately following clinical experiences, is a time when students have an opportunity to share, compare and engage critically in considering how these experiences impact on their learning. Reflective practice has merit in facilitating this process. Aim This project aimed to optimise the learning potential of practice-based experiences by enhancing midwifery students’ capacity for reflective practice through writing. Methods Design-based research was used to implement an educational intervention aimed at developing reflective practice skills and enhance reflective writing. The Bass Model of Holistic Reflection was introduced to promote the development of reflective capacity in midwifery students. Academics and midwifery students were provided with guidance and resources on how to apply the model to guide reflective writing. Students’ written reflections completed before (n = 130) and after the introduction of the intervention (n = 96) were evaluated using a scoring framework designed to assess sequential development of reflective capacity. Findings The pre-intervention scores ranked poorly as evidence of reflective capacity. All scores improved post-intervention. Conclusions The introduction of a holistic structured model of reflection resulted in improved scores across all five components of reflective writing; self-awareness, sources of knowledge, reflection and critical reflection, evidence informed practice and critical thinking. While further work is required the results show that the implementation process and use of the Bass Model enables students to demonstrate their capacity to reflect-on-practice through their writing.

Background Increasing global migration is resulting in a culturally diverse population in the receiving countries. In Australia, it is estimated that at least four thousand Sub-Saharan African women give birth each year. To respond appropriately to the needs of these women, it is important to understand their experiences of maternity care. Objective The study aimed to examine the maternity experiences of Sub-Saharan African women who had given birth in both Sub-Saharan Africa and in Australia. Design Using a qualitative approach, 14 semi-structured interviews with Sub-Saharan African women now living in Australia were conducted. Data was analysed using Braun and Clark’s approach to thematic analysis. Findings Four themes were identified; access to services including health education; birth environment and support; pain management; and perceptions of care. The participants experienced issues with access to maternity care whether they were located in Sub-Saharan Africa or Australia. The study draws on an existing conceptual framework on access to care to discuss the findings on how these women experienced maternity care. Conclusion The study provides an understanding of Sub-Saharan African women’s experiences of maternity care across countries. The findings indicate that these women have maternity health needs shaped by their sociocultural norms and beliefs related to pregnancy and childbirth. It is therefore arguable that enhancing maternity care can be achieved by improving women’s health literacy through health education, having an affordable health care system, providing respectful and high quality midwifery care, using effective communication, and showing cultural sensitivity including family support for labouring women.

Problem/background The Continuity of Care Experience is a mandated workplace based component of midwifery education in Australia. Since its inclusion in midwifery clinical education, the pedagogical approaches used across Australia have varied. Aim The purpose of this integrative review is to determine the outcomes of the Continuity of Care Experience as an educational model. Methods A search for relevant research literature was undertaken in 2015 using a range of databases and by examining relevant bibliographies. Articles published in English, which provided information about the outcomes of Continuity of Care Experiences for midwifery education were included. A total of 20 studies were selected. Findings The included studies were primarily exploratory and descriptive. Studies reported the value that both students and women place on the relationship they developed. This relationship resulted in opportunities that enhanced student learning by providing a context in which clinical practice learning was optimized. Challenges identified included managing time and workload pressures for students in relation to the CCE, inconsistencies in academic use of the experience, and variations in how the healthcare system influences the continuity experience. Conclusion No research was found that reports on the educational model in terms of defining learning objectives and assessment of outcomes. This represents an important omission in mandating this clinical practice model in midwifery curricula without sufficient guidance to unify and maximize learning for students. Research is required to explore the educational intent and assessment methods of the Continuity of Care Experience as an educational model.

Aim To report on a study measuring midwifery students’ self-reported abilities in teaching and supervising breastfeeding mothers. Abilities were assessed at two time intervals, before and after completing a maternal and infant nutrition topic with simultaneous clinical opportunities to consolidate their skills. Method A convenience sample of midwifery students in an Australian university completed a pre- and post-intervention survey to assess their self-rated ability to teach and supervise breastfeeding mothers. Rasch analysis was used to gain conjoint estimates of students’ self-reported abilities to teach and supervise breastfeeding mothers across 37 items with varying complexity of care needs. Rasch analysis was used to determine validity and reliability of the 37-item tool, to develop a hierarchical linear scale reflecting difficulty of breastfeeding supportive activities, and to determine student learning between the two time points. Results From 95 responses, 34 of the 37 items met the requirement for unidimensionality. Outcomes identified that midwifery students’ self-efficacy measures for breastfeeding support abilities can be reliably estimated. A hierarchical scale for learning these clinical skills has been generated to inform curricula development and learning processes. While there was an overall increase in the ease of difficulty of 21 items in the survey at time point two, eight items were identified as becoming more difficult. Conclusion The findings of this study challenge midwifery educators to reconsider the educational activities provided for midwifery students’ that aim to develop the requisite skills to provide effective breastfeeding support, including the provision of specific clinical opportunities to learn from breastfeeding women.