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Background A midwife’s ability to fully support women’s autonomy and self-determination with respect to midwifery care is often challenging. This is particularly true of water immersion for labour and birth. However, the woman’s agency over what happens to her body and that of her unborn baby should be key considerations for maternity care provision. Objectives A three phased mixed-methods study was undertaken to examine how water immersion policies and guidelines are informed. Phase three of this study captured the knowledge and experiences of Australian midwives, their support for water immersion and their experiences of using policies and guidelines to inform and facilitate the practice. Methods Critical, post structural, interpretive interactionism was used to examine more than 300 responses to three open-ended questions included in a survey of 233 midwives. Comment data were analysed to provide further insight, context and meaning to previously reported results. Findings Findings demonstrated a complex, multidimensional interplay of factors that impacted on both the midwife’s ability to offer and the woman’s decision to use water immersion under the themes ‘the reality of the system’, ‘the authoritative ‘others’’ and ‘the pseudo decision-makers’. Multiple scaffolded levels were identified, each influenced by the wider macro-socio-political landscape of Australian midwifery care. Conclusions The insight gained from examining midwives’ views and opinions of water for labour and birth, has aided in contextualising previously reported results. Such insight highlights the importance of qualitative research in challenging the status quo and working towards woman-centred practice and policy.

OBJECTIVE The objective of the review is to explore and evaluate women's experiences of interactions with health care providers during their postnatal period. INTRODUCTION The postnatal period is a transformative time for women. Women experience significant change and adaptation, which could impact upon parenting confidence, health, and psychological outcomes during this time. The interaction women have with their health care providers during the postnatal period plays an integral role in improving these health outcomes. INCLUSION CRITERIA This qualitative review will explore the experiences of primiparous and multiparous women during the postnatal period with a key focus on evaluating the interactions they have with health care providers. It will include all studies that utilize qualitative methods (such as interviews and focus groups). Articles that explore the postnatal care experiences of women who have endured a pregnancy loss, given birth to a baby with complex needs, or those that solely focus on describing the neonatal and intensive care experiences, will not be included. METHODS PubMed, CINAHL, Embase, Emcare, and PsycINFO will be searched. Studies published from 2000 onwards and written in English will be assessed for inclusion. Studies that are selected initially will be assessed for methodological quality by two independent reviewers utilizing the JBI critical appraisal instrument for qualitative research. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42020186384.

Aims: To gather, quality assess, synthesize and interpret the views, feeling, and experiences of women who used water immersion during labour and/or birth. Design: A systematic meta-thematic synthesis and GRADE-CERQual. Data sources: We searched MEDLINE, CINHAL, PsychINFO, AMED, EMBASE (MIDIRS only), LILACS, AJOL. Additional searches were carried out using Ethos (thesis database), cross-referencing against Google Scholar and citation chasing. Searches were carried out in August 2019, updated February 2020. Methods: Studies that met the selection criteria were appraised for quality. Data were extracted from the studies using meta-thematic analytical techniques; coding, descriptive findings, and analytical findings. The descriptive findings were subjected to confidence assessments using GRADE-CERQual. Results: Seven studies met the inclusion criteria. Nine key statements of findings were generated – one had high confidence, three moderate, three low and one very low confidence in the findings. The analytical findings generated three main themes: Liberation and Self-Emancipation, Synergy, transcendence and demarcation and Transformative birth and beyond. Overall, women experienced warm water immersion during labour and/or birth positively. Both the water and pool itself, facilitated women's physical and psychological needs during labour and/or birth, including offering effective analgesia. Our findings indicated that birthing pools are versatile tools that provide for a space that women can adapt and influence to best suit their individual needs. Conclusion: Women who used warm water immersion for labour and/or birth describe liberating and transformative experiences of welcoming their babies into the world. They were empowered, liberated, and satisfied. We recommend maternity professionals and services offer water immersion as a standard method of pain relief during labour/birth. Impact: Understanding women's experiences of labour and birth will inform future clinical practice. Midwives are optimally positioned to enhance women's access to water immersion. These findings have implications for education, guideline, and policy development as well as clinical practice. Refereed/Peer-reviewed

Refereed/Peer-reviewed Background: The 2011 and 2016 Stillbirth Lancet series made a call to action to identify mechanisms to reduce stillbirth stigma. This research answers that call, investigating the extent and dimensions of stillbirth stigma experienced by an international sample of mothers bereaved by stillbirth. Objective: To determine the prevalence and type as well as explore explanatory variables associated with higher levels of stillbirth stigma with bereaved mothers in high-income countries (Australia, United Kingdom, The United States of America and New Zealand). Method: An international survey of 889 bereaved mothers was conducted utilising the recently developed Still- birth Stigma Scale to explore the extent and types of stigma experienced, as well as the association between stigma and self-esteem (Rosenberg Self- Esteem Scales), perinatal grief (Perinatal Grief Scale), and perceived social sup- port (Perceived Social Support Scale). Demographic information (e.g. age, education, stillbirth history, sexual orientation and mental health) were collected to determine the association between individual demographic factors and stillbirth stigma. Results: Results of the Stillbirth Stigma Scale indicated that a majority (54%) of bereaved mothers experienced stigma. Self-stigma was the predominant type of stigma experienced (80%), followed by perceived devaluation (64.9%). Bereaved mothers also experienced discrimination (29.1%) and issues with disclosing their stillbirth to their community (36.7%). Stillbirth stigma scores were higher in bereaved mothers who had experienced the loss of their first child. High scores were associated with the mother’s mental health status (diagnoses prior to stillbirth, and/or after stillbirth (p < .05)).The other scales used indicated that higher stillbirth stigma scores were also associated with lower self-esteem (r (877) = -.304, p < .001), lower perceived social support (r (871) = -.448, p < .001) and higher levels of grief (r (829) = .609, p < .001) Conclusion: The current research was the first to identify that 54% of bereaved mothers experienced stigma, with self-stigma being the most prominent. Bereaved mothers endured discriminating experiences and had trouble disclosing their stillbirth to others within their community. The first-time mother with a self- reported history of mental illnesses appears to be the most at-risk of higher levels of stigma. Future longitudinal research needs to be conducted to determine the direction of the explanatory variables i.e. mental health, self-esteem and social support and develop interventions, which support the bereaved mother and reduce stillbirth stigma. Relevance: This study is the first to demonstrate the prevalence, extent, type and explanatory variables of stigma reported by bereaved mothers and the association between this and poorer outcomes including increased grief and decreased self-esteem. This study begins a dialogue about prevalence and explanatory variables of stillbirth stigma and its impact, to inform future prevention and support potential stigma reduction programs for community and bereaved mothers.

Clinical placement is a core feature of Australian midwifery education programs, with clinical supervision acknowledged as a key component for student success. The aim of this study was to evaluate the clinical facilitation models in South Australia, specifically the quality of clinical supervision to facilitate learning, and key stakeholder satisfaction. A mixed method evaluation research design was used to compare three models of clinical facilitation for midwifery students undertaking clinical placement across five venues. Midwifery students (n = 174), across two universities completed an anonymous e-survey utilising the validated Clinical Placement Experience Questionnaire. Midwives (n = 149) across five venues completed an anonymous purpose-designed questionnaire on their experience providing clinical supervision to midwifery students and Clinical Facilitators (n = 8) representing three facilitation models completed a self-report e-diary for two weeks and engaged in a focus group. Few differences were identified between the quality of student support and learning opportunities. Students in all models were well orientated and prepared for the clinical environment. Clinical Facilitators were supportive, educative and valuable for the students to achieve their learning objectives. One significant difference was that facilitators employed in the ‘Shared’ model were more able to provide support to midwives supervising students and maintain good liaison with the universities. Refereed/Peer-reviewed

Background: In 2011 and 2016, the Lancet Stillbirth Series released a call for action to identify mechanisms which could lead to a reduction in stillbirth stigma. Despite this repeated call, stillbirth stigma remains a relatively unexplored area. This research is answering that call by providing further psychometric assessment on the recently developed 20-item Stillbirth Stigma Scale.Methods:Bereaved parents (n=1015) from high-income countries (Australia, United States of America (USA), United Kingdom (UK), New Zealand and Canada) who have endured a stillbirth were surveyed. A confirmatory factor analysis was undertaken, to confirm the factor structure.Reliability analysis and convergent validity were conducted to further determine the reliability and validity of the scale. Ethics: This study was approved on 5 December 2016 by the University of South Australia Human Research Ethics Committee, protocol number 0000036017. Results: Based on the initial findings of the exploratory factor analysis, 20 items contained within four factors (Perceived Devaluation, Discrimination, Self-stigma and Disclosure) were entered into the confirmatory factor analysis. Results supported a four-factor structure of the Stillbirth Stigma Scale and goodness of fit measurements were satisfactory. Internal consistencies of each sub-scale, and the total scale were good (á =.89). Convergent validity was also established with other related measures (Rosenberg Self-esteem Scale). Conclusion: Analysis suggests the Stillbirth Stigma Scale is a theoretical and statistically sound scale, which can be used within health promotion and clinical settings to identify bereaved parents at risk of experiencing higher levels of stillbirth stigma.

Preparing students for communication in clinical healthcare settings can be challenging, particularly given it may be the first time they have considered how and why they communicate. The challenge is to find an effective process for the development of clinical communication skills in a highly content-driven curriculum. The objective of this study was to empower first-year midwifery students to reflect on their experiences of communication to inform and expand their clinical communication by drawing on two distinct disciplines - midwifery and linguistics. This paper reports on the findings of a study that examined the implementation of innovative, preparatory workshops for first-year midwifery students. Data from quantitative and qualitative surveys were collected pre- and post-workshop, and post-clinical placement, and analysed using linguistic mapping and thematic analysis. Perceptible shifts in self-evaluation of competence were noted post the workshop and clinical placement. Students developed and used metalanguage appropriately to describe and evaluate communication while demonstrating increased awareness of the complexity of professional communication. They were able to find a balance between the vital technical information, and the interpersonal aspects of communication. This impacted positively on their perception of women as partners. Refereed/Peer-reviewed

Background: Water immersion for labour and birth is an option that is increasingly favoured by women.Australian water immersion policies and guidelines commonly specify that practitioners, such as midwives, must undertake further education and training to become accredited. Method: A three-phase mixed methods approach was used. Phase one used critical discourse analysis to determine who or what informs policies and guidelines related to water immersion for labour and/or birth. Phase two examined policy and guideline informants’ experiences of the development of policies/guidelines, whilst phase three surveyed Australian midwives’ views and experiences of water immersion and their use of and/or involvement in the development of policies and guidelines. Findings: Practitioner accreditation for the facilitation of water immersion was a common finding across all phases of the study. An examination of policies and guidelines found that practitioners, namely midwives, were required to meet additional training requirements to facilitate water immersion.Participants of phases two and three identified and discussed accreditation as a significant challenge to the option of water immersion, particularly where there were inconsistencies across documents and in the interpretation of their content. Conclusion: The need for practitioners to be accredited to facilitate water immersion was identified as a major barrier to availability and therefore, women’s ability to access the option. Given these findings, the need for accreditation should be challenged. Refereed/Peer-reviewed

In 2015, 19,818 women gave birth in South Australia with 19,719 of these births occurring in hospitals.Of these, 81% gave birth in a metropolitan hospital. A total of 4,255 (21.5%) women gave birth in private hospitals whilst only 0.5% of all births occurred at home. The majority of women who received antenatal care did so from a public specialist led clinic (43.7%) followed by care from obstetricians (+/-midwives) in private practice (25.5%). Midwifery group practice (MGP) made up only 11.8% of antenatal care provided. Only 5.5% received care through a birth unit/centre all of which are situated in tertiary level centres. Outcomes as documented by the perinatal statistics unit over the past 10 years suggest that rates of intervention continue to increase resulting in lower rates of physiological birth. In 2015, 35% of women underwent a caesarean section, with a further 11.5% requiring assistance via forceps or ventouse. This means that only 53% of women experienced a normal spontaneous vaginal birth compared to 66.1% in 1981. The main reason for caesarean section was a previous caesarean with this followed by failure to progress, fetal distress and malpresentation. Interestingly, 32.5% of women had their labour synthetically initiated. This rate has increased significantly from 1981 where the rate was 22.1%. There is much argument around the reasons for increasing intervention in Australian maternity care however, one such argument suggests that medicalisation of what is otherwise a natural physiological process is a contributing factor. Given this, there has been much focus on strategies to assist and reduce intervention with the ultimate purpose of supporting women to birth with as little intervention as possible. Primary midwifery-led birthing units (PMUs) present a potential option for increasing maternity care services across the state of South Australia with the ultimate goals of keeping birth normal and ensuring safety and cost effectiveness. Refereed/Peer-reviewed

Background There is little published research that has examined practitioners’ views and experiences of pain relieving measures commonly used during labour and birth, particularly for non-pharmacological measures such as water immersion. Furthermore, there is minimal published research examining the process of policy and guideline development, that is, the translation of published research to usable practice guidance. Aims The aims of phase three of a larger study were to explore midwives knowledge, experiences and support for the option of water immersion for labour and birth in practice and their involvement, if any, in development of policy and guidelines pertaining to the option. Methods Phase three of a three phased mixed methods study included a web based survey of 234 Australian midwives who had facilitated and/or been involved in the development of policies and/or guidelines relating to the practice of water immersion. Findings Midwives who participated in this study were supportive of both water immersion for labour and birth reiterating documented benefits of reduced pain, maternal relaxation and a positive birth experience. The most significant concerns were maternal collapse, the difficulty of estimating blood loss and postpartum haemorrhage whilst barriers included lack of accredited staff, lifting equipment and negative attitudes. Midwives indicated that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice. Conclusion Midwives who participated in this study supported the practice of water immersion reiterating the benefits documented in the literature and minimal risk to the woman and baby. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

Objective The objective of this study was to explore the views, experiences, perceptions of and access to water immersion for labor and birth in Australia. Design A sequential exploratory mixed methods study commenced in 2016. The first phase involved an online survey. The second phase is due to commence in 2019 and will involve focus groups and interviews. This paper presents a subset of results from phase one that asked women to self-rate the benefits and risks associated with water use on Likert-scales and for those who had a previous birth not involving water, how the two experiences compared. Participants A total of 740 Australian women who had used water immersion for labor and/or birth rated the benefits against 7-point Likert scales and 736 responded to 5-point Likert scales relating to commonly cited concerns surrounding the option. Results Women highly rated water immersion against all benefits. Benefits that were most highly rated (by numbers of ‘entirely agree’ on 7-point Likert scales) included sense of safety (80.14%), an alert baby (75.00%), a positive birth experience (72.70%), water as soothing (72.03%) and freedom of movement (71.35%). Women were most concerned (by selecting ‘somewhat’ to ‘extremely concerned’ on 5-point Likert scales) about being told to get out of the water when they did not want to (n = 120/736, 16.30%), their contractions going away (n = 76/736, 10.33%) and unsupportive staff (n = 65/736, 8.83%). More than 90% (n = 682/740) of women mostly to entirely agreed that they would recommend water immersion to others. Women rated water immersion as more comfortable, more satisfying and more relaxing when compared to previous births that they had that did not involve water. Key conclusions Women value water immersion for labor and birth. They have very little to no concern for the most common adverse events as documented in the literature. Implications for practice The results add to the growing evidence base surrounding water immersion for labor and birth. Whilst there remains ongoing debate about the safety of water immersion, women's experiences should be considered alongside outcome data. The results of this study may assist policy makers and clinicians in their advocacy and support of women who choose water immersion. Ethical considerations The Human Research Ethics Committee of the University of South Australia approved the research.

The accessibility of water immersion (WI) for labour and/or birth is dependent on the views of the care provider/institution and the policies/clinical practice guidelines (CPGs) that underpin practice. With little quality research on the safety and efficacy of WI the policies and CPGs informing current practice lack the sound evidence base necessary to ensure they are well informed. The aims of the study were to determine how WI policies and/or CPGs are informed, who interprets the evidence to inform policy/guideline development and to what extent the policy/guideline facilitate the option of WI for labour and birth. This study used a mixed-methods approach that included a critical analysis of Australian policies/CPGs, semi-structured interviews with policy/guideline informants and a survey of views of Australian midwives. Thesis (PhD(Nursing))--University of South Australia, 2016. Includes bibliographical references (pages 291-311)