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Background: Despite strong evidence of benefits and increasing consumer demand for homebirth, Australia has failed to effectively upscale it. To promote the adoption and expansion of homebirth in the public health care system, policymakers require quantifiable results to evaluate its economic value. To date, there has been limited evaluation of the financial impact of birth settings for women at low risk of pregnancy complications., Objective: This study aimed to examine the difference in inpatient costs around birth between offering homebirth in the public maternity system versus not offering public homebirth to selected women who meet low-risk pregnancy criteria., Methods: We used a whole-of-population linked administrative dataset containing all women who gave birth in Queensland (one Australian State) between 01/07/2012 and 30/06/2018 where publicly funded homebirth is not currently offered. We created a static microsimulation model to compare the inpatient cost difference for mother and baby around birth based on the women who gave birth between 01/07/2017 and 30/06/2018 (n = 36,314). The model comprised of a base model - representing standard public hospital care, and a counterfactual model - representing a hypothetical scenario where 5 % of women who gave birth in public hospitals planned to give birth at home prior to the onset of labour (n = 1816). Costs were reported in 2021/22 AUD., Results: In our hypothetical scenario, after considering the effect of assumptive place and mode of birth for these planned homebirths, the estimated State-level inpatient cost saving around birth (summed for mother and babies) per pregnancy were: AU$303.13 (to Queensland public hospitals) and AU$186.94 (to Queensland public hospital funders). This calculates to a total cost saving per annum of AU$11 million (to Queensland public hospitals) and AU$6.8 million (to Queensland public hospital funders)., Conclusion: A considerable amount of inpatient health care costs around birth could be saved if 5 % of women booked at their local public hospitals, planned to give birth at home through a public-funded homebirth program. This finding supports the establishment and expansion of the homebirth option in the public health care system., Competing Interests: Conflict of interest None declared., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Problem: Little is known about the educational impact of providing routine, online feedback from women on midwifery student learning and clinical practice., Background: Feedback on students' clinical performance has historically been provided by lecturers and clinical supervisors. Women's feedback is not routinely collected or evaluated for impact on student learning., Aim: To evaluate the impact of women's feedback about continuity of care experiences with a midwifery student on learning and practice., Design: Descriptive, exploratory qualitative study., Methods: All second-and third-year Bachelor of Midwifery students undertaking clinical placement between February and June 2022 at one Australian university, submitted formative, guided written reflections on de-identified women's feedback they received through their ePortfolio. Data were analysed using reflexive thematic analysis., Findings: Forty-four of the 69 eligible students (64%) submitted reflections on feedback received. Three themes emerged: 1) Confidence boosting, 2) Deeply integrating Midwifery Metavalues, and 3) Enhancing commitment to continuity. Three subthemes: connection, future practice and advocacy were identified. Women's feedback positively impacts student learning and places the woman in the educational feedback loop., Conclusion: This study is an international first evaluating the impact of feedback from women on midwifery students' learning. Students reported greater confidence in their clinical practice, a deeper understanding of their midwifery philosophy, and an intention to advocate for, and work in, midwifery continuity models after graduation. Routine feedback about women's experiences should be embedded into midwifery education programs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors., Aim: To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making., Methods: We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was., Findings: CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour., Discussion and Conclusion: Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care., Competing Interests: Conflict of Interest The authors have no conflicts of interest to declare., (Copyright © 2022 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Pre-registration midwifery students in Australia are required to engage in a minimum of ten continuity of care experiences (CoCE). Students recruit and gain consent of each woman to provide CoCE under direct supervision of a registered health professional, usually a midwife. Clinical outcomes for women who had CoCE with a midwifery student placed in a continuity of midwifery care (CMC) or fragmented models are rarely reported., Aims: 1. analyse clinical outcomes for women experiencing CMC with CoCE by students; 2. analyse clinical outcomes for women in a fragmented care model with CoCE by students; and 3. compare clinical outcomes according to women's primary model of care., Methods: Students undertaking a Bachelor of Midwifery program at one Australian university recorded clinical outcomes for women experiencing CoCE during pregnancy [n=5972] and labour and birth [n=3933] in an e-portfolio. A retrospective, cohort design compared student recorded maternal data with National Core Maternity Indicators and Queensland Perinatal Data., Results: Midwifery students providing CoCE reported better or equal clinical outcomes for women compared to population data. Women receiving CoCE had reduced likelihood of tobacco smoking after 20 weeks of pregnancy, episiotomy, and third and fourth degree tears., Conclusions: Clinical outcomes for women in fragmented models of care and receiving CoCE by undergraduate, pre-registration midwifery students are equal to or better than State data across 12 variables. CoCE should be offered to all women early in their pregnancy to ensure optimal benefits. Acknowledging midwifery students' potential to make positive impacts on women's clinical outcomes may prompt more health services to reconceptualise and foster CoCE., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Little is known about what midwifery leaders need to effectively contribute to maternity services reform., Background: Despite evidence establishing midwifery continuity of care as the gold standard of maternity care, implementation of these models has been slow. Midwives in health service leadership roles are in an ideal position to re-orientate maternity services to midwifery continuity of care., Question: What do midwives in leadership positions need in order to be effective in contributing to the reform of maternity services in Australia?, Methods: This qualitative descriptive study used purposive sampling to recruit 13 midwifery leaders from across Australia. Individual telephone interviews were conducted and analysed through line-by-line coding and identification of themes., Findings: Five main themes emerged from the data: 'core leadership skills and education are essential'; 'motivation and commitment to implementing evidence-based maternity care'; 'ability to create and sustain strategic relationships'; 'bringing the vision to life' which contained two sub-themes of 'changing the culture' and 'reaching midwifery's full potential'; and, 'organisational support and commitment are key to maternity reform'., Discussion: This study echoes findings from previous research emphasising the importance of leadership attributes and development opportunities for midwifery leaders. Additional needs of midwifery leaders were also revealed, which have not yet been extensively explored in the literature, including a strong commitment to continuity of care, effective relationships with key stakeholders and support from healthcare executives., Conclusion: Midwifery leaders need to be equipped to contribute to maternity care reform through leadership development opportunities, effective relationships and support from healthcare executives., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring., Aim: To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring., Methods: Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed., Findings: Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible., Discussion and Conclusion: Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common., Aim: This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system., Methods: An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours., Findings: The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system., Discussion: The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety., Conclusion: This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Aim: To investigate the experiences, perspectives and plans of students who had a six-month placement with the midwifery group practice., Methods: Focus groups were conducted with fifteen third - year Bachelor of Midwifery students who had undertaken an extended placement at a midwifery group practice in a large tertiary referral hospital in Queensland, Australia., Results: Four main themes were identified in the data: Expectations of the Placement; Facilitating learning within a midwifery group practice model; Transitioning between models of care and Philosophy and culture of midwifery group practice., Discussion and Conclusion: Third-year midwifery students valued the experience of working one-on-one for an extended placement with a midwife providing continuity of care within a caseload model. The experience was the highlight of their degree and they learned 'how to be a midwife'. Most students found reintegrating back into the hospital system of care challenging, reporting that their developed skills of supporting women holistically and facilitating normal birth were not fully utilised when returning to the task-orientated birth suite. Students valued thoughtful, kind and supportive midwifery preceptors who supported them to transition back into the hospital., Implications and Recommendations: Undertaking an extended placement within a midwifery group practice provides students with a rich and holistic learning experience and helps them develop a sense of professional identity. Student placements situated within models of care which provide continuity of midwifery care should be proactively enabled by health services and universities. Research of the longer-term impacts of an extended midwifery group practice clinical placement on midwifery graduates' capabilities and competencies 3-5 years post registration should be conducted., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Pre-registration midwifery students in Australia undertake a minimum of ten continuity of care experiences with childbearing women. However, women are rarely asked to formally evaluate this care by students., Aim: To evaluate data from a routine, web-based survey of women about having a midwifery student provide a continuity of care experience., Methods: All women (n=886) recruited by a midwifery student for a continuity of care experience during a 12 month period received an email inviting them to complete an online survey. The survey included personal details, experiences of care, and two scales on Respect and Satisfaction., Results: A response rate of 57% (n=501) was achieved. On average students attended six antenatal visits (mean=5.83) and had six postnatal contacts with women. Most students attended labour and birth (92.6% n=464). Most women rated overall satisfaction with care by their student as 'better than they had hoped'. Positive correlations were found between number of antenatal visits and postnatal contact with students on both levels of satisfaction and respect felt by women. Women felt more satisfied when their midwifery student attended labour and birth., Conclusions: The online survey was feasible and provided valid and reliable feedback from women about their student during a continuity of care experience. Women valued having an ongoing relationship with a student during pregnancy, labour and birth, and postpartum. Pre-registration midwifery education programs should continue to privilege relationship-based care and national standards should support the effective integration of continuity of care experiences., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Little is known about midwives' knowledge and skills to assess and promote maternal health literacy., Aims: To test the reliability and validity of a new tool to assess midwives' health literacy knowledge, skills and attitudes., Methods: Using a cross-sectional design, midwives were recruited through professional and social media networks. The online survey included demographic and professional questions and a new measure on midwives' health literacy knowledge, skills and attitudes. Convergent validity was assessed using ten items from the Caring Assessment Scale. Perceived barriers to promoting maternal health literacy were sought., Findings: Three hundred and seven participants completed the survey. A two-factor solution accounted for 41% of variance and resulted in 14 items, including all attitude items, being removed. Cronbach's alpha reliability was acceptable (Skills=.76; Knowledge=.66). Convergent validity was established. Most midwives (77.1%, n=221) reported giving limited attention to formally assessing women's health literacy. Between 30 to 60% of midwives never or only sometimes used specific techniques to promote maternal health literacy. Most (75%, n=201) had not received education about health literacy., Discussion and Conclusions: The new Transforming Maternity Care Collaborative Health Literacy tool was valid and reliable. Few midwives formally assessed or promoted women's health literacy. Midwives require education about maternal health literacy assessment and promotion to ensure women understand information being conveyed. A large national survey of midwives using the new tool is recommended., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: In countries where education programmes are assessed as meeting international standards there is limited knowledge about the challenges facing midwifery education., Background/aim: The positive impact of quality midwifery education on maternal and newborn health is acknowledged by the World Health Organisation. However, there is limited research identifying the issues faced in providing quality midwifery education. The aim of this study was to identify the challenges and determine priority projects to strengthen midwifery education across Australia and New Zealand., Methods: A two-round Delphi study with experts in midwifery education was undertaken., Findings: In round one, 85 participants identified an initial 366 issues for midwifery education. Through thematic content analysis these were categorised into 89 statements reflecting five major themes: In round two, 105 midwifery experts from Australia n=86 (79%) and New Zealand n=23 (21%) rated the 89 statements in order of priority. Across the combined data (Australia and New Zealand) a total of 19 statements gained consensus of ≥80%., Discussion: Five priority themes were identified including; (1) enabling success of First Peoples/Māori midwifery students; (2) increasing the visibility and influence of midwifery within regulation, accreditation and university governance; (3) determining how best to deliver the clinical practicum component of programmes; (4) reviewing midwifery programmes to enhance design, content and delivery; and (5) ongoing education and support for the midwifery workforce., Conclusion: In Australia and New Zealand, it is imperative that collaborative work is undertaken to design and action identified projects addressing these priorities., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Continuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers' Advisory Council, few women in Australia have access to such models., Background: Extensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice., Aim: This paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women., Methods: A scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis., Findings: Two narrative themes emerged: (1) Hospital accreditation: 'Here to stay' but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care., Discussion: Regulatory frameworks drive hospitals' priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible., Conclusions: Structural changes to Australia's health accreditation system are needed to prioritise, and mandate, continuity of midwifery care., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Ensuring an adequate supply of the midwife workforce will be essential to meet the future demands for maternity care within Australia., Background: Aim: To project the overall number of midwives registered with the Nursing and Midwifery Board of Australia and the timing of their retirement to 2043 based upon the ageing of the population., Methods: Using data on the number of registered midwives released by the Nursing and Midwifery Board of Australia we calculated the five-year cumulative attrition rate of each five-year age group. This attrition rate was then utilized to estimate the number of midwives registered in each five-year time period from 2018 to 2043. We then estimated the number of midwives that would be registered after also accounting for stated retirement intentions., Findings: Between 2018 and 2023 the overall number of registered midwives will decline from 28,087 to 26,642. After this time there is expected to be growth in the total number, reaching 28,392 in 2028 and 55,747 in 2043. If midwives did relinquish their registration at a rate indicated in previous workforce satisfaction surveys, the overall number of registered midwives would decline to 19,422 in 2023, and remain below 2018 levels until 2038., Discussion: Due to the age distribution of the current registered midwifery workforce the imminent retirement of a large proportion of the workforce will see a decline in the number of registered midwives in the coming years. Additional retirement due to workforce dis-satisfaction may exacerbate this shortfall., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

COVID-19 is causing a major once-in-a-century global pandemic. The scientific and clinical community is in a race to define and develop effective preventions and treatments. The major features of disease are described but clinical trials have been hampered by competing interests, small scale, lack of defined patient cohorts and defined readouts. What is needed now is head-to-head comparison of existing drugs, testing of safety including in the background of predisposing chronic diseases, and the development of new and targeted preventions and treatments. This is most efficiently achieved using representative animal models of primary infection including in the background of chronic disease with validation of findings in primary human cells and tissues. We explore and discuss the diverse animal, cell and tissue models that are being used and developed and collectively recapitulate many critical aspects of disease manifestation in humans to develop and test new preventions and treatments.

Background: Little emphasis has been given to the standardised measurement of midwifery students' perceptions of their clinical learning experiences., Aim: To develop a tool that evaluates students' perceptions of their clinical learning experiences according to environment and impact of preceptors on professional development., Methods: A cross-sectional design was used. Tool development had three phases: item generation; expert review to assess clarity, apparent internal consistency and content validity; and psychometric testing. All Bachelor of Midwifery students at one university in Australia were invited to complete the online survey. Psychometric testing included dimensionality, internal consistency and test-retest reliability., Results: A 74% (n=279) response rate was achieved. Factor analysis revealed the Clinical Learning Environment Scale and Impact of the Midwifery Preceptor Scale accounting for 53.6% and 71.5% of variance respectively. Both scales were reliable (Cronbach's alpha=.92 and .94) and valid. Overall, students positively rated the clinical learning environment and preceptors' abilities to foster their sense of identity as a midwife. Students were less satisfied with preceptors' understanding of the academic program., Discussion: The new tool consists of two scales that reliably measure midwifery students' perceptions of how the clinical learning environment develops their skills and reflects a midwifery philosophy. Preceptors had a positive influence on students' skills and professional development., Conclusions: The Midwifery Student Evaluation of Practice tool is the first valid and reliable measure of students' perceptions of their clinical learning experiences. Students' feedback provides valuable information to educators and preceptors on how best to optimise clinical learning., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: Caesarean section rates have risen in high-income countries. One of the potential drivers for this is the widespread use of CTG monitoring., Background: Intrapartum cardiotocograph monitoring is considered to be indicated for women at risk for poor perinatal outcome., Aim: This systematic literature review with meta-analysis examined randomised controlled trials and non-experimental research to determine whether cardiotocograph monitoring rather than intermittent auscultation during labour was associated with changes in perinatal mortality or cerebral palsy rates for high-risk women., Methods: A systematic search for research published up to 2019 was conducted using PubMed, CINAHL, Cochrane, and Web of Science databases. Non-experimental and randomised controlled trial research in populations of women at risk which compared intrapartum cardiotocography with intermittent auscultation and reported on stillbirth, neonatal mortality, perinatal mortality and/or cerebral palsy were included. Relative risks were calculated from extracted data, and meta-analysis of randomised controlled trials was undertaken., Findings: Nine randomised controlled trials and 26 non-experimental studies were included. Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates. The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy., Discussion: Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome., Conclusion: There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Continuity of midwifery care is the best maternity care model for women at any risk level, and there is a global imperative to improve access to midwifery-led care. However, diverse perspectives about how best to prepare graduates for working in midwifery continuity of care models persist. The continuity of care experience standard in Australia was anticipated to address this., Aim: To challenge the dearth of published information about the structures and processes in midwifery education programs by identifying: the educational value and pedagogical intent of the continuity of care experience; issues with the implementation, completion and assessment of learning associated with continuity of care experience; and discuss curriculum models that facilitate optimal learning outcomes associated with this experience. We discuss the primacy of continuity of care experience in midwifery education programs in Australia., Discussion: The inclusion of continuity of care experience in midwifery programs in Australia became mandatory in 2010 requiring 20, however this number was reduced to 10 in 2014. Research has shown the beneficial outcomes of continuity of care experience to both students and women. Continuity of care experience builds mutual support and nurturing between women and students, fosters clinical confidence, resilience, and influences career goals. We require curriculum coherence with both structural and conceptual elements focusing on continuity of care experience., Implications and Recommendations: Education standards that preference continuity of care experience as the optimal clinical education model with measurable learning outcomes, and alignment to a whole of program philosophy and program learning outcomes is required., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Exposure to alcohol prenatally can result in a child being diagnosed with fetal alcohol spectrum disorder. Affected infants experience lifelong impairments that can involve, physical, cognitive, behavioural and emotional difficulties that impact on their functional capacity. Effective prevention of fetal alcohol spectrum disorder is critically needed in Australia. Reduction in the prevalence of this disorder will only be possible if we prevent alcohol consumption during pregnancy., Aim: This paper provides an overview of fetal alcohol spectrum disorder and discusses the role of caseload midwifery as part of a multi-level prevention approach., Findings: Drawing on previous research, caseload midwifery has potential to support the prevention of fetal alcohol spectrum disorder through continuity of care., Conclusion: Prevention of fetal alcohol spectrum disorder will be more likely if women experience a supportive relationship with a known midwife, who has received appropriate training and can enable women to feel comfortable in discussing and addressing alcohol use., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Relatively little is known about the extent of trauma and birth-related fear in midwives and how this might affect practice., Aim: (1) Determine prevalence of birth related trauma and fear in midwives and associations with midwives' confidence to advise women during pregnancy of their birth options and to provide care in labour. (2) Describe midwives' experiences of birth related trauma and/or fear., Method: A mixed methods design. A convenience sample of midwives (n=249) completed an anonymous online survey. Descriptive and inferential statistics were used to analyse the quantitative data. Latent content analysis was used to extrapolate meaning from the 170 midwives who wrote about their experiences of personal and/or professional trauma., Results: The majority of midwives (93.6%) reported professional (n=199, 85.4%) and/or personal (n=97, 41.6%) traumatic birth experiences. Eight percent (n=20) reported being highly fearful of birth. Trauma was not associated with practice concerns but fear was. Midwives categorised as having 'high fear' reported more practice concerns (Med 23.5, n=20) than midwives with 'low fear' (Med 8, n=212) (U=1396, z=-3.79, p<0.001, r=0.24). Reasons for personal trauma included experiencing assault, intervention and stillbirth. Professional trauma related to both witnessing and experiencing disrespectful care and subsequently feeling complicit in the provision of poor care. Feeling unsupported in the workplace and fearing litigation intensified trauma., Conclusion: High fear was associated with lower confidence to support childbearing women. Fear and trauma in midwives warrants further investigation to better understand the impact on professional practice., (Copyright © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Psychoeducation counselling delivered by midwives has been demonstrated to reduce maternal fear and improve women's confidence for birth. Translating the evidence in practice presents challenges. A systematic approach to the implementation of evidence and evaluation of this process can improve knowledge translation., Aim: To implement and evaluate the translation of psychoeducation counselling on (1) midwives' knowledge, skills and confidence to provide the counselling; (2) perceived barriers and enablers to embedding the psychoeducation counselling in practice; and (3) pregnant women's levels of fear., Methods: Using a mixed methods approach, data were collected using a pre (n=22) and post (n=21) training survey, recorded interviews (n=17), diaries (n=6), and retrospective audit of fear of birth scores. Data were analysed using descriptive statistics, independent sample t-tests, and chi-square tests. Latent content analysis was used to analyse the qualitative data., Results: Training in the counselling framework significantly improved midwives' knowledge, skills and confidence to counsel women on psychosocial issues and reduce fear scores for women reporting high childbirth fear. The main barriers to midwives introducing counselling into routine care related to the fragmentation of care delivery during pregnancy. Conversely continuity of care by a known midwife was considered an enabler., Conclusion: Psychoeducation provided by midwives is of benefit to women experiencing high levels of birth fear. While psychoeducation training was successful in enhancing midwives' knowledge, skills and confidence; embedding the counselling framework in everyday practice was challenging. Counselling is more easily implemented within midwifery caseload models which enable midwives to build relationships with women across their pregnancy., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Continuity of midwifery care contributes to significant positive outcomes for women and babies. There is a perception that providing continuity of care may negatively impact on the wellbeing and professional lives of midwives., Aim: To compare the emotional and professional wellbeing as well as satisfaction with time off and work-life balance of midwives providing continuity of care with midwives not providing continuity., Method: Online survey. Measures included; Copenhagen Burnout Inventory (CBI); Depression, Anxiety and Stress Scale-21; and Perceptions of Empowerment in Midwifery Scale (PEMS-Revised). The sample (n=862) was divided into two groups; midwives working in continuity (n=214) and those not working in continuity (n=648). Mann Whitney U tests were used to compare the groups., Results: The continuity group had significantly lower scores on each of the burnout subscales (CBI Personal p=.002; CBI Work p<.001; CBI Client p<.001) and Anxiety (p=.007) and Depression (p=.004) sub-scales. Midwives providing continuity reported significantly higher scores on the PEMs Autonomy/Empowerment subscale (p<.001) and the Skills and Resources subscale (p=.002). There was no difference between the groups in terms of satisfaction with time off and work-life balance., Conclusion: Our results indicate that providing continuity of midwifery care is also beneficial for midwives. Conversely, midwives working in shift-based models providing fragmented care are at greater risk of psychological distress. Maternity service managers should feel confident that re-orientating care to align with the evidence is likely to improve workforce wellbeing and is a sustainable way forward., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Several risk factors for negative birth experience have been identified, but little is known regarding the influence of social and midwifery support on the birth experience over time., Objective: The aim of this study was to describe women's birth experience up to two years after birth and to detect the predictive role of satisfaction with social and midwifery support in the birth experience., Method: A longitudinal cohort study was conducted with a convenience sample of pregnant women from 26 community health care centres. Data was gathered using questionnaires at 11-16 weeks of pregnancy (T1, n=1111), at five to six months (T2, n=765), and at 18-24 months after birth (T3, n=657). Data about sociodemographic factors, reproductive history, birth outcomes, social and midwifery support, depressive symptoms, and birth experience were collected. The predictive role of midwifery support in the birth experience was examined using binary logistic regression., Results: The prevalence of negative birth experience was 5% at T2 and 5.7% at T3. Women who were not satisfied with midwifery support during pregnancy and birth were more likely to have negative birth experience at T2 than women who were satisfied with midwifery support. Operative birth, perception of prolonged birth and being a student predicted negative birth experience at both T2 and T3., Conclusions: Perception of negative birth experience was relatively consistent during the study period and the role of support from midwives during pregnancy and birth had a significant impact on women's perception of birth experience., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Reporting the outcomes for women and newborns accessing private midwives with visiting rights in Australia is important, especially since this data cannot currently be disaggregated from routinely collected perinatal data., Aim: 1) Evaluate the outcomes of women and newborns cared for by midwives with visiting access at one Queensland facility and 2) explore private midwives views about the structures and processes contributing to clinical outcomes., Methods: Mixed methods. An audit of the 'all risk' 529 women receiving private midwifery care. Data were compared with national core maternity variables using Chi square statistics. Telephone interviews were conducted with six private midwives and data analysed using thematic analysis., Findings: Compared to national data, women with a private midwife were significantly more likely to be having a first baby (49.5% vs 43.6% p=0.007), to commence labour spontaneously (84.7% vs 52.7%, p<0.001), experience a spontaneous vaginal birth (79% vs 54%, p<0.001) and not require pharmacological pain relief (52.9% vs 23.1%, p<0.001). The caesarean section rate was significantly lower than the national rate (13% vs 32.8%, p<0.001). In addition fewer babies required admission to the Newborn Care Unit (5.1% vs 16%, p<0.001). Midwives were proud of their achievements. Continuity of care was considered fundamental to achieving quality outcomes. Midwives valued the governance processes embedded around the model., Conclusions: Private midwives with access to the public system is safe. Ensuring national data collection accurately captures outcomes relative to model of care in both the public and private sector should be prioritised., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem or Issue: Rates of elective and unplanned caesarean section continue to increase in high income countries. Evidence-based clinical guidelines aim to promote and support normal birth but are rarely evaluated., What Is Already Known: The Queensland Normal Birth Guideline was developed in consultation with stakeholders and disseminated to public and private hospitals and released in 2012. Impact of the Guideline on practice has not been investigated., What This Paper Adds: Although most midwives (90%) were aware of the guideline, only 71% reported that it routinely guided practice.

Objective: The rate of caesarean section continues to increase, and there is evidence that childbirth fear is a contributing factor. Insufficient evidence is available on the impact of reducing childbirth fear on health-related quality of life and health service use. We undertook an economic evaluation of a psycho-education counselling intervention offered by midwives to address women's fear of childbirth in Australia., Methods: Pregnant women (n = 339) with high childbirth fear were randomised to a midwife-led psycho-education intervention for childbirth fear or to usual care. This paper presents the economic evaluation of the intervention based on health-related quality of life and health service use from recruitment to six weeks postpartum (n = 184)., Results: The changes in health-related quality of life after birth (EQ-5D-3L: 0.016 vs. 0.010, p = 0.833, for usual care and intervention) and total health care use cost (AUS$10,110 vs. AUS$9980, p = 0.819) were similar between groups. The intervention did not increase costs; however, in a post hoc analysis, the interventions might be cost-effective for those women with very high childbirth fear., Conclusion: This brief psycho-education intervention by midwives did not improve the health-related quality of life of women, and had no impact on overall cost., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives., Aim: To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress., Methods: Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms., Findings: More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma., Discussion: Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder., Conclusion: Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Evidence is emerging of the benefits to students of providing continuity of midwifery care as a learning strategy in midwifery education, however little is known about the value of this strategy for midwifery students., Aim: To explore Indigenous students' perceptions of providing continuity of midwifery care to Indigenous women whilst undertaking a Bachelor of Midwifery., Methods: Indigenous Bachelor of Midwifery students' experiences of providing continuity of midwifery care to Indigenous childbearing women were explored within an Indigenous research approach using a narrative inquiry framework. Participants were three Indigenous midwifery students who provided continuity of care to Indigenous women., Findings: Three interconnected themes; facilitating connection, being connected, and journeying with the woman. These themes contribute to the overarching finding that the experience of providing continuity of care for Indigenous women creates a sense of personal affirmation, purpose and a validation of cultural identity in Indigenous students., Discussion and Conclusions: Midwifery philosophy aligns strongly with the Indigenous health philosophy and this provides a learning platform for Indigenous student midwives. Privileging Indigenous culture within midwifery education programs assists students develop a sense of purpose and affirms them in their emerging professional role and within their community. The findings from this study illustrate the demand for, and pertinence of, continuity of care midwifery experiences with Indigenous women as fundamental to increasing the Indigenous midwifery workforce in Australia. Australian universities should provide this experience for Indigenous student midwives., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Midwifery prescribing was introduced in Australia in 2010 and is available to those notated as Medicare Eligible. Only 59% of Medicare Eligible midwives are endorsed prescribers., Aim: To explore and describe Australian midwives views of prescribing including the barriers and enablers to prescribing., Methods: Online survey. Eligible participants were Australian midwives who had completed an educational programme required for endorsement as a midwifery prescriber (n=131). Descriptive statistics and content analysis were used to analyse the data set., Results: Sixty-six midwives entered data (50% response rate). Twelve midwives (18%) had commenced prescribing. Prescribers agreed that being able to prescribe enhanced women's access to medicines and role satisfaction. The most common barriers to initiating prescribing were regulatory issues and processes, and no pathway to support midwifery prescribing in the public sector. The enabling factors most commonly reported were supportive relationships, education and personal factors such as motivation, knowledge and confidence., Conclusion: Prescribing was viewed positively by midwives, but only a small proportion of suitably educated midwives were able to translate this into prescribing. Prolonged and complicated registration processes, restrictive drug formularies, and a lack of prescribing roles for public sector midwives were clear barriers. Supportive professional relationships, quality education and personal motivation and confidence assisted midwives in overcoming these barriers. Offering mentoring may help midwives to move into prescribing practice and use it in a manner that best meets the health needs of women and infants in midwifery care., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: The Australian national midwifery education standards require students to complete a number of continuity of care (COC) experiences. There is increasing evidence outlining the value of this experience to the student, but there is limited research examining women's experiences of having a COC midwifery student. This study aimed to investigates the woman's experiences., Methods: A retrospective descriptive cohort design was used. A paper-based survey was posted to all women cared for by a midwifery student in 2013 (n=698). Descriptive statistics were used to explore the proportion, mean score, standard deviation and range of the variables. Construct validity of the Satisfaction and Respect Scales was tested using exploratory factor analysis. Free text responses were analysed using latent content analysis., Result: One-third of women returned a completed survey (n=237/698, 34%). There was a significant positive correlation (p<0.05) between the number of AN/PN visits a midwifery student attended and women's levels of satisfaction. Women were very satisfied with having a student midwife provide continuity. The qualitative data provided additional insight demonstrating that most women had a positive relationship with the midwifery student that enhanced their childbearing experience., Conclusion: The women in this study valued continuity of midwifery care and were able to form meaningful relationships with their midwifery student. Programs leading to registration as a midwife should privilege continuity of care experiences. Not only does this benefit women but provides the future midwifery workforce with a clear understanding of models that best meet women's individual and the benefits of working in these models., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Within the context of an ageing health workforce it is important to gain a greater understanding of the motivations of young people (aged less than 21 years) to choose a career in midwifery., Aim: To explore the reasons why young students decided to study midwifery and enrol in one Australian Bachelor of Midwifery program., Method: A descriptive exploratory qualitative design was used. Eleven midwifery students aged less than 21 years on enrollment participated in a semi-structured tape-recorded interview. The transcribed interviews were analysed using thematic analysis., Findings: Direct and indirect exposure to positive constructions of childbirth as well as the midwives role fuelled young student's fascination with midwifery and drove their desire to enrol. While some young students entered midwifery studies as a result of their 'love of babies' others took a more pragmatic 'wait and see' approach about their career choice. Many young students however clearly distinguished midwifery from nursing demonstrating an intention to be a midwife rather than a nurse. This decision often took place within the context of opposition from within their family, school and social networks where the public discourse continued to reinforce nursing as the preferred pathway to midwifery., Conclusion: Creating opportunities for young people to be exposed to positive constructions of childbirth as well as midwifery role models may increase the number of young students entering midwifery. There is also a need for information to be provided to school careers officers to assist them to understand the distinction between midwifery and nursing., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: The WDEQ-A is the most widely used measure of childbirth fear in pregnant women; however there is increasing discussion in the literature that simpler, more culturally transferrable tools may offer a better solution to identifying fearful women in clinical practice., Aim: To compare the two item Fear of Birth Scale (FOBS) with the 33 item WDEQ-A in a large cohort of Australian pregnant women., Method: Self-report questionnaires during second trimester including Wijma Delivery Expectancy Questionnaire (WDEQ-A) and Fear of Birth Scale (FOBS). Correlation of FOBS and WDEQ-A was tested using Spearman's correlation coefficients. Receiver operating characteristic (ROC) curve assessed the sensitivity and specificity of possible cut-points on the FOBS against WDEQ-A cut-point of ≥85. Sensitivity, specificity, positive and negative predictive values were determined. Fearful and non-fearful women as classified by both instruments were compared for differences in demographic, psycho-social and obstetric characteristics., Results: 1410 women participated. The correlation between the instruments was strong (Spearman's Rho = 0.66, p < 0.001). The area under the ROC was 0.89 indicating high sensitivity with a FOBS cut-point of 54. Sensitivity was 89%, specificity 79% and Youden index 0.68. Positive predictive value was 85% and negative predictive value 79%. Both instruments identified high fear as significantly associated with first time mothers, previous emergency caesarean and women with self-reported anxiety and/or depression. Additionally FOBS identified a significant association between fearful women and preference for caesarean., Conclusion: This study supports the use of the FOBS in clinical practice to identify childbirth fear in pregnant women., (Crown Copyright © 2015. Published by Elsevier B.V. All rights reserved.)

We have previously reported that the steroid hormone estrogens stimulate activation of sphingosine kinase 1 (SphK1) and sphingosine-1-phosphate (S1P) receptors in breast cancer cells. Both estrogens and S1P are potent biological modulators of endothelial function in vasculature able to activate multiple effectors, including endothelial nitric oxide synthase (eNOS). In this study we report that treatment of endothelial cells (ECs) with 17β-estradiol (E2) resulted in a rapid, transient, and dose-dependent increase in SphK activity and increased S1P production. The effect was not reproduced by the inactive E2 analogue 17α-E2. Expression of the dominant-negative mutant SphK1(G82D) or transfection of SphK1-targeted siRNA in ECs caused not only a defect in SphK activation by E2, but also a significant inhibition of E2-induced activation of Akt/eNOS. Furthermore, E2 treatment induced internalization of plasma membrane S1P1 receptor, accompanied with an increase in the amount of cytosolic S1P1. By down-regulating S1P1 receptor expression, the S1P1-specific antisense oligonucleotides significantly inhibited E2-induced activation of Akt/eNOS in ECs. E2-induced EC migration and tube formation were also inhibited by S1P1 down-regulation. Thus, the findings indicate an important role of the SphK1/S1P1 pathway in mediating estrogen signaling and its actions in vasculature., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Low intensity anxiety in pregnancy is normal however high levels of fear affect between 20% and 25% of women, with around 10% suffering severe levels. Research from Scandinavian countries includes women with severe levels of fear, with little work undertaken in Australia. This paper explores predictors of fear and the relative benefits of screening women for childbirth fear at high or severe levels., Method: A secondary analysis of data collected for the BELIEF study was conducted to determine differences for demographic, psycho-social and obstetric factors in women with severe fear (W-DEQ ≥85, n=68) compared to women with less or no fear (n=1318). Women with severe fear (W-DEQ ≥85, n=68) were also compared to those with high fear scores (W-DEQ ≥66-84, n=265). Logistic regression modelling was used to ascertain if screening for high or severe levels of fear is most optimal., Results: 1386 women completed the W-DEQ. There were no differences on demographic variables between women with severe or high fear. Depression symptoms, decisional conflict and low self-efficacy predicted high and severe fear levels. Nulliparity was a predictor of high fear. A previous operative birth and having an unsupportive partner were predictors of high fear in multiparous women., Conclusion: Psychosocial factors were associated with both high and severe fear levels. Screening for severe fear may detect women with pre-existing mental health problems that are exacerbated by fear of birth. Australian women with high childbirth fear levels (W-DEQ ≥66) should be identified and provided appropriate support., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: In 2010 Australian Government reform of maternity services enabled midwives to access Medicare. This significant change provides midwives with new opportunities to engage in patterns of working that provide continuity of care to childbearing women. There remains limited evidence, however, on midwives perceptions of how the reforms impact them both personally and professionally., Aim: This research examined midwives' perceptions of their role and how, in light of the reform agenda, they might conceptualise a change in working patterns and environment to provide greater levels of continuity of care., Method: A qualitative descriptive approach was employed using the four-stage Appreciative Inquiry model. Twenty-three midwives from three maternity units within south-east Queensland participated in one of six focus groups. Thematic iterative analysis was employed to identify empirical codes and examine relationships within and across the data., Findings: Midwives endorsed the reforms and considered the concept of continuity of midwifery care as fundamental to achieving a woman centred maternity system. Most participants, however, found it difficult to conceptualise how they might contribute to any level of system change. In addition the majority passively accepted the status quo of their employing organisation and believed they were powerless to effect change., Conclusion: In order to promote the growth of evidence based continuity of care models midwives need to work to their full scope of practice. Strong midwifery leadership is required to enable midwives to re-conceptualise roles and work patterns and identify how they can engage with and contribute to reform of maternity services., (Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

The recent multistate outbreak of a multidrug-resistant (MDR) Salmonella Heidelberg strain from commercial poultry production highlights the need to better understand the reservoirs of these zoonotic pathogens within the commercial poultry production and processing environment. As part of a larger study looking at temporal changes in microbial communities within the major water tanks within a commercial processing facility, this paper identifies and characterizes Salmonella enterica isolated from the water in a final scalder tank at 3 times during a typical processing day: prior to the birds entering the tank (start), halfway through the processing day (mid), and after the final birds were scalded (end). Over 3 consecutive processing days, no Salmonella were recovered from start-of-day water samples, while a total of 56 Salmonella isolates were recovered from the mid-day and end-of-day scalder water samples. Traditional and newer PCR-based serotyping methods eventually identified these isolates as either group C3 S. Kentucky (n=45) and group B S. Heidelberg (n=11). While none of the S. Kentucky isolates possessed any resistances to the antimicrobials tested, all S. Heidelberg isolates were found to be multidrug resistant to 5 specific antimicrobials representing 3 antimicrobial classes. Due to the potential public health impact of S. Heidelberg and the recent nationwide poultry-associated outbreak of multidrug-resistant S. Heidelberg, future studies should focus on understanding the transmission and environmental growth dynamics of this serotype within the commercial poultry processing plant environment., (© 2015 Poultry Science Association Inc.)

Background: Unexplained late gestation stillbirth is a significant health issue. Antenatal information about foetal movements has been demonstrated to reduce the stillbirth rate in women with decreased foetal movements. Midwives are ideally placed to provide this information to women., Aim: To investigate pregnant women's perceptions of information about foetal movements and preferences for receiving information., Methods: This prospective, descriptive study was conducted in the antenatal clinic of a large metropolitan maternity hospital., Findings: Pregnant women (n=526) at 34 weeks gestation or later were recruited. Only 67% of women reported receiving information about foetal movements. Women reported that midwives (80%), family (57%), friends (48%) and own mother (48%) provided this information. Midwives were the most preferred source of information. Around half (52%) of the women used the internet for information but only 11% nominated the web as their preferred information source., Conclusion: Women prefer to be given as much information about foetal movements as possible. Women favour information from health professionals, mainly from a midwife. Midwives are well-placed to partner with pregnant women and give them unbiased and evidenced based information enabling them to make decisions and choices regarding their health and well-being. While the internet is a prevalent information source, women want to be reassured that it is trustworthy and want direction to reliable pregnancy related websites., (Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background and Aim: Pregnant women who smoke are rarely consulted in the design and evaluation of the interventions that target them. In Australia, women will typically be counselled for smoking cessation as a part of routine antenatal care. However this approach achieves only modest rates of cessation. This study aimed to privilege the perspectives of women from low socioeconomic backgrounds who are most likely to smoke during pregnancy and who are less likely to quit spontaneously., Methods: Guided by feminist principles, in-depth interviews were undertaken with a purposive sample of six pregnant women, who resided in lower socioeconomic status areas in South Australia. Their experiences and views of being part of a smoking cessation intervention in metropolitan Adelaide were explored. Transcriptions were thematically analysed using an inductive approach and an open coding framework., Findings: An over-arching theme of 'missed opportunities' and four inter-related sub-themes encapsulated the predominantly negative experiences of the intervention for the women. The women's interest in quitting was hindered by a didactic communication style employed by maternity care professionals. The participants' information and support needs were reported as being superficially managed by maternity care professionals or Quitline workers who provided care in routine ways., Conclusions: These findings indicate that smoking cessation interventions and associated Quitline support needs to become more personalised and sensitive to the needs of women who face barriers posed by complex socio-economic disadvantage. These findings have important policy and practice implications for Australian public maternity care settings where smoking cessation interventions are embedded., (Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Marked differences exist between the maternal and neonatal outcomes of Australian Aboriginal and Torres Strait Islander women and their babies compared with the outcomes for other Australian women and their babies. Australian government policies underline the need to increase the number of practising Aboriginal and Torres Strait Islander midwives and nurses as a strategy for delivering culturally appropriate healthcare to improve health outcomes for Aboriginal and Torres Strait Islander families. Additional challenges are experienced by Aboriginal and/or Torres Strait Islander midwifery students providing Continuity of Care (COC) to Australian Aboriginal and/or Torres Strait Islander childbearing women. One such example is the challenge presented due to the close connections and relationships that exist within some Aboriginal and/or Torres Strait Islander cultures in terms of the maintenance of a professional relationship, in particular, the maintenance of professional boundaries. Whilst there is a growing body of evidence on the benefits to women of continuity of midwifery care models, little is known about the experiences of Aboriginal and Torres Strait Islander women who receive COC from Aboriginal and Torres Strait Islander midwifery students., Aim: To explore the experiences of Australian Aboriginal and Torres Strait Islander childbearing women who participated in a Continuity of Care journey with an Aboriginal and/or Torres Strait Islander Bachelor of Midwifery student., Methods: Exploratory, descriptive study using semi-structured interviews informed by an Indigenous Research Methodology., Findings: Thematic analysis identified four major themes: (i) communicating our way, (ii) the role of relationships, (iii) support and assistance and (iv) challenges of the system. The findings illustrated the benefits Aboriginal women experience as a result of having Aboriginal and/or Torres Strait Islander midwifery students provide Continuity of Care., Conclusion: Increasing the number of Australian Aboriginal and/or Torres Strait Islander midwives is essential to improving health outcomes for Australian Aboriginal and Torres Strait Islander childbearing women and their families. Caseload midwifery models with Aboriginal and Torres Strait Islander midwives across Australia are needed. Health services, in partnership with Universities and Aboriginal and Torres Strait Islander communities, have a vital role to play in the development and expansion of these models., (Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Purpose: To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity., Background: Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40., Method: Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women., Results: 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%)., Conclusion: Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended., (Copyright © 2013 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: The aim of the study was to describe the level of burnout in midwives working at a maternity unit in South East Queensland, Australia., Method: A self-administered questionnaire was distributed to all registered midwives (N=110) working at the study site during November 2011. The questionnaire included a demographic survey and the Copenhagen Burnout Inventory. Fifty-eight (52.7%) staff completed the package. Data was entered into SPSS database version 19 and descriptive statistics were used to determine means, ranges and frequencies., Results: Almost 30% of the sample experienced moderate to high levels of burnout some 50% of participants scored moderate to high for personal burnout with a similar number scoring high for work-related burnout. In comparison, burnout related to working with clients was very low. Differences between participants were associated with years of experience, area of work and employment position (FT/PT, level of position and work area). Participants aged 35years or younger and with less than 10years midwifery experience scored highest on the personal and work-related domains whereas participants over 35years scored highest within the client-related domain. Midwives at level 1 (lowest pay group) scored highest for work-related burnout and client-related burnout. Midwives in more senior positions (level 2 and above) scored highest for personal burnout., Conclusion: Personal and work-related burnout was high in this group of midwives while burnout related to caring for women was low. These results provide insight into the emotional health of midwives in one maternity unit. While more work is needed, strategies to decrease and/or prevent burnout may include clinical mentorship and reorganising models of maternity care to increase work satisfaction and autonomy and strengthen relationships between midwives and women., (Copyright © 2013 Australian College of Midwives. All rights reserved.)

For patients hospitalized with pneumonia, guidelines provide empirical antibiotic recommendations and some studies suggest that macrolide/β-lactam combinations are preferable. We hypothesized that guideline-concordant regimens, particularly macrolide/β-lactams, would reduce mortality and ICU admissions. All patients hospitalized with pneumonia in Edmonton, Alberta, Canada, were managed according to a clinical pathway and enrolled in a population-based registry. Clinical data, Pneumonia Severity Index and treatments were collected. Guideline-concordant regimens were macrolides/β-lactams or respiratory fluoroquinolone monotherapy. The main outcome was in-hospital mortality. The study included 3203 patients and most had severe pneumonia (63% PSI Class IV-V). Three hundred and twenty-one (10.0%) patients died, 306 (9.6%) were admitted to the ICU and 570 (17.8%) achieved the composite of death or ICU admission. Most (n = 2506) patients received guideline-concordant antibiotics. Receipt of guideline-concordant antibiotics was not associated with a reduction in mortality alone (231 (9.2%) vs. 90 (12.9%); adjusted odds ratio (aOR), 0.82; 95% CI, 0.61-1.09; p 0.16), but was associated with decreased death or ICU admission (14.7% vs. 29.0%; aOR, 0.44; 95% CI, 0.36-0.54; p < 0.0001). Within guideline-concordant subgroups, there was no difference in mortality between macrolide/β-lactams and respiratory fluoroquinolone monotherapy (22 (8.3%) vs. 209 (9.3%); aOR, 1.09; 95% CI, 0.66-1.81; p 0.73) but macrolide/β-lactams were associated with increased odds of death or ICU admission (17.4% vs. 14.4%; aOR, 1.58; 95% CI, 1.09-2.27; p 0.01). In conclusion, guideline-concordant antibiotics were not associated with decreased mortality for patients hospitalized with pneumonia, but were associated with a decrease in the composite endpoint of death or ICU admission. Our findings do not support any clinical advantage of macrolide/β-lactam compared with respiratory fluoroquinolone monotherapy., (© 2012 The Authors. Clinical Microbiology and Infection © 2012 European Society of Clinical Microbiology and Infectious Diseases.)

Objective: The aim of this study was to apply a region-specific method for the statistical analysis of landmark configurations to a rapid maxillary expansion data set obtained from cone-beam computerized tomography., Study Design: A method of analyzing landmark configurations using persistent homology and dimensionality reduction is used to analyze region-specific treatment effects involving 2 types of maxillary expansion treatments, compared with a control group., Results: The method identified maxillary width as the primary feature of variability in the data and showed that both treatment groups exhibited significantly greater maxillary expansion than the control group throughout the study period, with no significant differences found between the 2 treatments., Conclusions: The choice of distance used to compare landmark configurations and the focus on more specific regions of interest produce more detailed results. This approach can be used after a primary analysis with a larger number of landmarks has identified regions deserving further inquiry., (Copyright © 2013 Elsevier Inc. All rights reserved.)