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Background: The health and wellbeing of midwives are important considerations for workforce retention and quality care. The occurrence and relationships among mental health conditions such as burnout and depression have received little attention. We investigated the prevalence of burnout, depression, anxiety and stress in Australian midwives.Methods: An online survey was conducted in September 2014. Participants were recruited through the Australian College of Midwives and professional networks. The survey sought personal and professional details. Standard measures included the Copenhagen Burnout Inventory (CBI) (Personal, Work and Client subscales), and Depression, Anxiety, and Stress Scale (DASS). The sample was collapsed into two groups according to DASS clinical cut-offs (normal/mild versus moderate/severe/extreme). Effect size statistics were calculated and judged according to Cohen's guidelines.Results: One thousand thirty-seven surveys were received. Respondents were predominantly female (98%), with an average age of 46.43 years, and 16.51 years of practice. Using a CBI subscale cut-off score of 50 and above (moderate and higher), 64.9% (n = 643) reported personal burnout; 43.8% (n = 428) reported work-related burnout; and 10.4% (n = 102) reported client-related burnout. All burnout subscales were significantly correlated with depression, anxiety and stress, particularly personal and work-related burnout with Spearman's rho correlations ranging from .51 to .63 (p < .001). Around 20% of midwives reported moderate/ severe/ extreme levels of depression (17.3%); anxiety (20.4%), and stress (22.1%) symptoms. Mann-Whitney U tests revealed significant differences between groups with depression (r = .43), anxiety (r = .41) and stress (r = 48) having a medium size effect on burnout.Conclusion: Prevalence of personal and work-related burnout in Australian midwives was high. The physical and psychological exhaustion associated with the different types of burnout were reflected in symptoms of depression, anxiety and stress symptoms. Further research is needed to support the personal well-being of midwives and minimize workplace burnout by developing short and long term strategies. [ABSTRACT FROM AUTHOR]

Background: Fear of childbirth has negative consequences for a woman's physical and emotional wellbeing. The most commonly used measurement tool for childbirth fear is the Wijma Delivery Expectancy Questionnaire (WDEQ-A). Although originally conceptualized as unidimensional, subsequent investigations have suggested it is multidimensional. This study aimed to undertake a detailed psychometric assessment of the WDEQ-A; exploring the dimensionality and identifying possible subscales that may have clinical and research utility. Methods: WDEQ-A was administered to a sample of 1410 Australian women in mid-pregnancy. The dimensionality of WDEQ-A was explored using exploratory (EFA) and confirmatory factor analysis (CFA), and Rasch analysis. Results: EFA identified a four factor solution. CFA failed to support the unidimensional structure of the original WDEQ-A, but confirmed the four factor solution identified by EFA. Rasch analysis was used to refine the four subscales (Negative emotions: five items; Lack of positive emotions: five items; Social isolation: four items; Moment of birth: three items). Each WDEQ-A Revised subscale showed good fit to the Rasch model and adequate internal consistency reliability. The correlation between Negative emotions and Lack of positive emotions was strong, however Moment of birth and Social isolation showed much lower intercorrelations, suggesting they should not be added to create a total score. Conclusion: This study supports the findings of other investigations that suggest the WDEQ-A is multidimensional and should not be used in its original form. The WDEQ-A Revised may provide researchers with a more refined, psychometrically sound tool to explore the differential impact of aspects of childbirth fear. [ABSTRACT FROM AUTHOR]

We investigated the impact of pre-existing mental ill health on postpartum maternal outcomes. Women reporting childbirth trauma received counselling (Promoting Resilience in Mothers' Emotions; n = 137) or parenting support ( n = 125) at birth and 6 weeks. The EuroQol Five dimensional (EQ-5D)-measured health-related quality of life at 6 weeks, 6 and 12 months. At 12 months, EQ-5D was better for women without mental health problems receiving PRIME (mean difference (MD) 0.06; 95 % confidence interval (CI) 0.02 to 0.10) or parenting support (MD 0.08; 95 % CI 0.01 to 0.14). Pre-existing mental health conditions influence quality of life in women with childbirth trauma. [ABSTRACT FROM AUTHOR]

Background: Just over 300,000 women give birth in Australia each year. It is important for health care providers, managers, and policy makers know what women want from their care so services can be provided appropriately. This review is a part of the Midwifery Futures Project, which aims to prepare the midwifery workforce to best address the needs of women. The aim of this review was to describe and analyse current literature on the maternity care needs of women in Australia., Methods: A scoping review methodology was used, guided by the Joanna Briggs Institute framework. A systematic search of the literature identified 9023 studies, and 59 met inclusion criteria: being peer-reviewed research focusing on maternity care needs, conducted in Australian populations, from 2012 to 2023. The studies were analysed using inductive content analysis., Results: Four themes were developed: Continuity of care, being seen and heard, being safe, and being enabled. Continuity of care, especially a desire for midwifery continuity of care, was the central theme, as it was a tool supporting women to be seen and heard, safe, and enabled., Conclusion: This review highlights that women in Australia consistently want access to midwifery continuity of care as an enabler for addressing their maternity care needs. Transforming Australian maternity care policy and service provision towards continuity would better meet women's needs., Competing Interests: Declaration of Competing Interest Caroline Homer declares she is the current Editor-in-Chief of Women & Birth. The Deputy Editor, Prof Linda Sweet, managed this submission and made the final decision. All other authors have no further conflicts to declare., (Copyright © 2024 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: 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.)

Objective: Technologies for fetal heart rate monitoring have been widely introduced despite evidence of no improvement in perinatal outcomes. A significant body of research has raised concerns that healthcare information technologies can have unintended consequences. We sought to describe an unintended consequence of central fetal monitoring technology., Design: The research was conducted as an Institutional Ethnography. Data generated from interviews, focus groups, and observations were analysed to generate an account of midwives' experiences with the central fetal monitoring system., Setting: The birthing unit of one Australian maternity service with a central fetal monitoring system., Informants: 34 midwives and midwifery students who worked with the central fetal monitoring system., Findings: Midwives described a disruptive social event they named being K2ed. Clinicians responded to perceived cardiotocograph abnormalities by entering the birth room despite the midwife not having requested assistance. Being K2ed disrupted midwives' clinical work and generated anxiety. Clinical communication was undermined, and midwives altered their clinical practice. Midwives performed additional documentation work to attempt to avoid being K2ed., Key Conclusions: This is the first report of an unintended consequence relating to central fetal monitoring, demonstrating how central fetal monitoring technology potentially undermines safety by impacting on clinical and relational processes and outcomes in maternity care., Implications for Practice: Current evidence does not support implementation or ongoing use of central fetal monitoring systems. Further research is needed to inform scaling down central fetal monitoring systems in a safe and supported way., Competing Interests: Declaration of Competing Interest All authors have no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Hence, no conflict of interest is being declared., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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.)

Background: There is growing body of evidence that suggests many midwives are unhappy and as a result are making decisions to leave the profession., Aim: Determine the incidence of midwives indicating their intention to leave the profession and explore the reasons for this decision including what might cause midwives to be dissatisfied., Method: Data analysed was collected as part of the Australian arm of the Work, Health and Emotional Life of Midwives (WHELM) project. Descriptive statistics and latent content analysis was used to analysis the data set., Results: Almost half (42.8%, n=443/1037) the midwives had considered leaving the profession in the preceding six months. The qualitative and quantitative data aligned with 'dissatisfaction with the organisation of midwifery care' and/or 'dissatisfaction with my role as a midwife' being the two commonest reasons behind the intention to leave. Early career midwives were most likely to consider leaving the profession (p=.05) due to dissatisfaction with their role. Almost half the midwives who had considered leaving the profession were most dissatisfied with managers (p=<.001)., Conclusion: Midwives felt their ability to provide quality maternity care was constrained by a fragmented medicalised system that did not work for the women in their care or themselves. The results of this study add to a growing call for policy makers and health care providers to reorientate maternity services to enable women to build positive longitudinal relationships with midwives. Not only will this improve maternal and neonatal outcomes but provide a satisfying and sustainable way for working for midwives., (Copyright © 2019 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: 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.)

Background: the predicted midwifery workforce shortages in several countries have serious implications for the care of women during pregnancy, birth and post partum. There are a number of factors known to contribute to midwifery shortages and work attrition. However, midwives assessment of their own professional identity and role (sense of empowerment) are perhaps among the most important. There are few international workforce comparisons., Aim: to compare midwives' sense of empowerment across Australia, New Zealand and Sweden using the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised)., Method: a self-administered survey package was distributed to midwives through professional colleges and networks in each country. The surveys asked about personal, professional and employment details and included the Perceptions of Empowerment in Midwifery Scale-R (PEMS-Revised). Descriptive statistics for the sample and PEMS were generated separately for the three countries. A series of analysis of variance with posthoc tests (Tukey's HSD) were conducted to compare scale scores across countries. Effect size statistics (partial eta squared) were also calculated., Results: completed surveys were received from 2585 midwives (Australia 1037; New Zealand 1073 and Sweden 475). Respondents were predominantly female (98%), aged 50-59 years and had significant work experience as a midwife (+20 years). Statistically significant differences were recorded comparing scores on all four PEMS subscales across countries. Moderate effects were found on Professional Recognition, Skills and Resources and Autonomy/Empowerment comparisons. All pairwise comparisons between countries reached statistical significance (p<.001) except between Australia and New Zealand on the Manager Support subscale. Sweden recorded the highest score on three subscales except Skills and Resources which was the lowest score of the three countries. New Zealand midwives scored significantly better than both their Swedish and Australian counterparts in terms of these essential criteria., Discussion/conclusions: midwives in New Zealand and Sweden had a strong professional identity or sense of empowerment compared to their Australian counterparts. This is likely the result of working in more autonomous ways within a health system that is primary health care focused and a culture that constructs childbirth as a normal but significant life event. If midwifery is to reach its full potential globally then developing midwives sense of autonomy and subsequently their empowerment must be seen as a critical element to recruitment and retention that requires attention and strengthening., (Copyright © 2016 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.)

Background: High levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention., Method: Between May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here., Results: 1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93). Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the 'decision aid' helped reduce their fear (53 % vs 37 %, p = 0.02)., Conclusion: Following a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies., Trial Registration: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012.

Collaborative partnerships between health care providers and academics are essential in the provision of quality undergraduate midwifery programs. While health care providers often contribute to clinical assessment and teaching in midwifery programs, they are rarely involved in assessment design and evaluation. This paper describes the evaluation of an assessment task designed to develop critical thinking skills in final year undergraduate midwifery students. Health care providers' involvement sought to confirm the authenticity and validity of the assessment task and facilitate further engagement. A mixed method descriptive study design was used. After reviewing a sample of student work, health care providers completed a 20 item survey and participated in a focus group. Survey items were based on the domains of Educational Acceptability, Educational Impact and Preparation for Practice. Participants gave high scores for each domain and commented positively on the innovative nature of the assessment, students' ability to undertake in-depth analysis of complex cases, and development of student's critical thinking skills. Participants also reported greater confidence in students' competence and the program. Involving health care providers in evaluation of an assessment task validated the assessment, contributed to clinicians' perceptions of student credibility, and fostered strong links between the program and industry., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: A newborn baby is removed from his/her mother into formal care when he/she is considered at risk of serious harm and it is not in the best interests to go home with their parent(s) or carer(s). In New South Wales (NSW), this removal is known as an "assumption of care". This process is challenging for all involved especially when it occurs soon after birth. There is very limited research to inform midwives in this area of practice., Aim: To explore the experiences of midwives who had been involved in the assumption of care of a baby soon after birth or in the early postnatal period., Method: A qualitative descriptive approach was used. Ten midwives involved with the assumption of care of a baby were interviewed. A thematic analysis was undertaken., Findings: There were two overarching themes. "Being in the head space" represented the activities, tasks and/or processes midwives engaged in when involved in an assumption of care. "Being in the heart space" described the emotional impact on midwives, as well as their perceptions on how women were affected., Conclusion: Midwives described feeling unprepared and unsupported, in both the processes and the impact of assumption of care. They were confronted by this profound emotional work and described experiencing professional grief, similar to that felt when caring for a woman experiencing a stillbirth. In the future, midwives need to be provided with support to ensure that they can effectively care for these women and also manage the emotional impact themselves., (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.)

Background: Childbirth confidence is an important marker of women's coping abilities during labour and birth. This study investigated socio-demographic, obstetric and psychological factors affecting self-efficacy in childbearing women., Method: This paper presents a secondary analysis of data collected as part of the BELIEF study (Birth Emotions - Looking to Improve Expectant Fear). Women (n = 1410) were recruited during pregnancy (≤24 weeks gestation). The survey included socio-demographic details (such as age and partner support); obstetric details including parity, birth preference, and pain; and standardised psychological measures: CBSEI (Childbirth Self-efficacy Inventory), W-DEQ A (childbirth fear) and EPDS (depressive symptoms). Variables were tested against CBSEI first stage of labour sub-scales (outcome expectancy and self-efficacy expectancy) according to parity., Results: CBSEI total mean score was 443 (SD = 112.2). CBSEI, W-DEQ, EPDS scores were highly correlated. Regardless of parity, women who reported low childbirth knowledge, who preferred a caesarean section, and had high W-DEQ and EPDS scores reported lower self-efficacy. There were no differences for nulliparous or multiparous women on outcome expectancy, but multiparous women had higher self-efficacy scores (p < .001). Multiparous women whose partner was unsupportive were more likely to report low self-efficacy expectancy (p < .05). Experiencing moderate pain in pregnancy was significantly associated with low self-efficacy expectancy in both parity groups, as well as low outcome expectancy in nulliparous women only. Fear correlated strongly with low childbirth self-efficacy., Conclusion: Few studies have investigated childbirth self-efficacy according to parity. Although multiparous women reported higher birth confidence significant obstetric and psychological differences were found. Addressing women's physical and emotional wellbeing and perceptions of the upcoming birth may highlight their level of self-efficacy for birth., Trial Registration: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17(th) May 2012.

Background: Childbirth fear has received considerable attention in Scandinavian countries, and the United Kingdom, but not in Australia. For first-time mothers, fear is often linked to a perceived lack of control and disbelief in the body's ability to give birth safely, whereas multiparous women may be fearful as a result of previous negative and/or traumatic birth experiences. There have been few well-designed intervention studies that test interventions to address women's childbirth fear, support normal birth, and diminish the possibility of a negative birth experience., Methods/design: Pregnant women in their second trimester of pregnancy will be recruited and screened from antenatal clinics in Queensland, Australia. Women reporting high childbirth fear will be randomly allocated to the intervention or control group. The psycho-educational intervention is offered by midwives over the telephone at 24 and 34 weeks of pregnancy. The intervention aims to review birth expectations, work through distressing elements of childbirth, discuss strategies to develop support networks, affirm that negative childbirth events can be managed and develop a birth plan. Women in the control group will receive standard care offered by the public funded maternity services in Australia. All women will receive an information booklet on childbirth choices. Data will be collected at recruitment during the second trimester, 36 weeks of pregnancy, and 4-6 weeks after birth., Discussion: This study aims to test the efficacy of a brief, midwife-led psycho-education counselling (known as BELIEF: Birth Emotions - Looking to Improve Expectant Fear) to reduce women's childbirth fear. 1) Relative to controls, women receiving BELIEF will report lower levels of childbirth fear at term; 2) less decisional conflict; 3) less depressive symptoms; 4) better childbirth self-efficacy; and 5) improved health and obstetric outcomes., Trial Registration: Australian New Zealand Controlled Trials Registry ACTRN12612000526875.

Background: Water birth involves the complete birth of the baby under warm water. There is a lack of consensus regarding the safety of water birth., Aim: This study aimed to describe the maternal and neonatal outcomes associated with water birth among labouring women deemed at low risk for obstetric complications and compare these outcomes against women of similar risk who had a standard land birth., Method: A retrospective audit and comparison of women giving birth in water with a matched cohort who birthed on land at Bankstown hospital over a 10 year period (2000-2009)., Results: In total 438 childbearing women were selected for this study (N=219 in each arm). Primigravida women represented 42% of the study population. There was no significant difference in mean duration of both first and second stages of labour or postpartum blood loss between the two birth groups. There were no episiotomies performed in the water birth arm which was significantly different to the comparison group (N=33, p<0.001). There were more babies in the water birth group with an Apgar score of 7 or less at 1min (compared to land births). However, at 5min there was no difference in Apgar scores between the groups. Three of eight special care nursery admissions in the water birth group were related to feeding difficulties., Conclusion: This is the largest study on water birth in an Australian setting. Despite the limitations of a retrospective audit the findings make a contribution to the growing body of knowledge on water birth., (Crown Copyright © 2012. 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.)

Objective: to describe perceptions of participating in a study testing the effectiveness of a perinatal emotional support intervention (Promoting Resilience in Mothers Emotions; PRIME) by women identified as experiencing emotional distress after birth., Design: qualitative descriptive approach. Semi-structured telephone interviews with 33 women recruited as part of a larger RCT to test the efficacy of a counselling intervention (PRIME). Women who received either (1) the intervention (counselling (or PRIME)) (n=16), (2) active control (Parenting support) (n=12), or (3) matched control (standard care) (n=5), were interviewed at 12 months postpartum. Thematic analysis of data was used., Findings: 'promoting reflection' and 'feeling cared for', were phrases that all participants used to describe their experience in the project regardless of group allocation. Women receiving PRIME reported 'getting in touch with (their) feelings' and 'moving on' as beneficial outcomes. Two women who received counselling reported 'having things left unresolved' indicating that their needs had not been met. Some women in both the active control and intervention identified that contact was 'nice but not hugely helpful or needed'., Implications and Conclusions: positive outcomes of PRIME were evident and most participants desired postpartum contact. Some women needed additional follow up and targeted assistance. Findings support the importance of providing personalised postnatal care that addresses women's emotional health needs., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Internationally, women give mixed reports regarding professional support during the early establishment of breastfeeding. Little is known about the components of midwifery language and the support practices, which assist or interfere with the early establishment of breastfeeding. In this study, critical discourse analysis has been used to describe the language and practices used by midwives when supporting breastfeeding women during the first week after birth. Participant observation at two geographically distant Australian health care settings facilitated the collection of 85 observed audio-recorded dyadic interactions between breastfeeding women and midwives during 2008-2009. Additionally, 23 interviews with women post discharge, 11 interviews with midwives and four focus groups (40 midwives) have also been analysed. Analysis revealed three discourses shaping the beliefs and practices of participating midwives. In the dominant discourse, labelled 'Mining for Liquid Gold', midwives held great reverence for breast milk as 'liquid gold' and prioritised breastfeeding as the mechanism for transfer of this superior nutrition. In the second discourse, labelled 'Not Rocket Science', midwives constructed breastfeeding as 'natural' or 'easy' and something which all women could do if sufficiently committed. The least well-represented discourse constructed breastfeeding as a relationship between mother and infant. In this minority discourse, women were considered to be knowledgeable about their needs and those of their infant. The language and practices of midwives in this approach facilitated communication and built confidence. These study findings suggest the need for models of midwifery care, which facilitate relationship building between mother and infant and mother and midwife., (© 2012 Blackwell Publishing Ltd.)

Introduction: despite an exponential rise in the number of medically initiated elective caesarean sections over the last two decades, women's experiences of this birth mode remain largely unknown. The aim of this study was to address this gap by describing women's experiences of medically necessary elective caesarean section., Methods: a grounded theory approach was used to collect and analyse interview data collected from 28 Australian women who had an elective caesarean section for a medical reason, 14 of whom were also observed during their caesarean section. The analyses of the non-participant observations were used to contextualise the women's experiences., Findings: prior to having their baby, women expected to play an active part in their caesarean section and to be supported to take up their 'mother' role as soon as their baby was delivered. Postnatally however, they reported having felt invisible, superfluous and disregarded during the event. There was evidence that hospital routines and processes contributed to women feeling displaced and unimportant in their baby's birth. Three sub-categories were formed from the analysis of the data that together are represented by the in-vivo label 'off everyone's radar'. These were 'just another case on an operating list', 'striving to be included while trying to behave' and 'unable to be my baby's mum'., Discussion: our findings suggest that when women are ignored during childbirth, any fear they hold may escalate into peritraumatic disassociation, which in turn has implications for women's postnatal mental and emotional health in the short and long term. In addition, the separation of the mother-baby dyad was found to have a devastating impact on maternal-newborn attachment that lasted well into the postnatal period. To optimise women's childbirth satisfaction and foster their attachment to their baby, both of which are essential for ongoing emotional well-being, it is vital that they are located at the centre of their birth experience and that if at all possible they are not separated from their newborn., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: The findings presented in this paper describe the beliefs and attitudes of three different groups of adolescent females about teen motherhood. These were elicited from a larger analysis that explored and theorized contraceptive pathways in a sample of young Australian women., Methods: A purposive sample of females aged 14 to 19 years was recruited from three distinct populations in the city of Perth, Western Australia: (1) never-pregnant; (2) pregnant-terminated; and (3) pregnant-continued. Grounded theory principles were used to analyze data generated from 69 semi-structured interviews conducted over a 21 month period (2006-2008)., Results: Two categories that described teenagers' attitudes to pregnancy and motherhood were elicited from the analysis. These explained the level of priority that teenagers placed on using contraception and postponing the transition to parenthood. The category labeled 'life derailment' represented how those who had never had a pregnancy or had terminated a pregnancy constructed teen motherhood as potentially restricting their personal, career and social transition to adulthood. The alternative category, 'life-line', reflected how those who continued with their pregnancy perceived teen motherhood as a positive and transformative experience that fostered personal growth., Conclusions: The findings from this study contribute further insight into the complex nature of adolescent contraceptive use and pregnancy risk. The analysis has strengthened evidence of the critical role of self-perceptions of pregnancy and childbearing on teenagers' fertility outcomes. It has also emphasized the broader life circumstances that shape these attitudes, intentions and related behavior. Strategies directed toward academic support and vocational skill development may broaden teenage girls' perceived future options and achievement capacity, thus influencing key reproductive health outcomes., (Copyright © 2011 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Midwives are the main health professional group providing support and assistance to women during the early establishment of breastfeeding. In published accounts of early breastfeeding experiences women report high levels of dissatisfaction with health professional support. To gain an understanding of this dissatisfaction, we examined the way in which midwives represent breastmilk and construct breastfeeding women in their interactions. Seventy seven women and seventy six midwives at two maternity units in NSW, Australia, participated in this study. Eighty five interactions between a midwife and a breastfeeding woman were observed and audio recorded during the first week after birth. In addition, data were collected through observation of nine parenting education sessions, interviews with 23 women following discharge, and 11 managers and lactation consultants (collected between October 2008 and September 2009). Discourse analysis was used to analyse the transcribed interactions, and interview data. The analysis revealed that midwives prioritised both colostrum and mature breastmilk as a 'precious resource', essential for the health and wellbeing of the infant and mother. References to breastmilk as 'liquid gold' were both verbal and implied. Within this discourse, the production and acquisition of 'liquid gold' appeared to be privileged over the process of breastfeeding and women were, at times, positioned as incompetent operators of their bodily 'equipment', lacking knowledge and skill in breastfeeding. In this context breastfeeding became constructed as a manufacturing process for a demanding consumer. The approach taken by midwives revealed an intensive focus on nutrition to the exclusion of relational communication and support. The findings indicate the need to challenge the current 'disciplinary' and 'technological' practices used by midwives when providing breastfeeding support and the need for a cultural change in postnatal care., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: To examine how the Australian media portrays the childbearing body through the use of celebrity stories in women's magazines. The study aimed to provide insight into socially constructed factors that might influence women's body image and expectations during pregnancy and the early postnatal period., Method: Media content analysis was used to analyse 25 celebrity stories about the childbearing postnatal body (images and texts) collected from Australia's three leading women's magazines between January and June 2009 (n=58)., Findings: A variety of persuasive textual and visual messages were elicited. The major theme representing how the postnatal body was constructed was labelled 'Bouncing back'; the focus of this paper. The social messages inherent in the magazine stories were that women need to strive towards regaining a pre-pregnant body shape with the same effort one would employ when recovering from an illness. Three specific sub-themes that promoted weight loss were identified. These were labelled 'Racing to bounce back', 'Breastfeeding to bounce back' and 'Pretending to bounce back'. A fourth sub-theme, 'Refusing to bounce back: Celebrating my new body', grouped together stories about celebrities who appeared to embrace their changed, but healthy, postnatal body., Conclusions: The study highlighted the expectations of the postpartum body in relation to speedy return to the pre-pregnant state. Understanding how these portrayals may contribute to women's own body image and expectations in the early postpartum period may better assist maternity health care providers to engage with women in meaningful discussions about this important time in their lives and challenge notions of ideal body types. Assisting women to accept and nurture themselves and have confidence in their ability as a new parent is a crucial element of quality maternity service provision., (Copyright © 2011 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

This paper is an empirically informed opinion piece revisiting an argument published in Midwifery 10 years ago, that the increasing professionalisation of breast feeding was not supporting women in Australia in sustaining breast feeding. We present the last 10 years of primary research on the topic, explore major policy initiatives and the establishment and growth of lactation consultants in Australia to see if this has made a difference to sustained rates of breast feeding. We present an analysis of the only consistently collected national statistics on breast feeding and compare this with national and state level government data collections from the last decade. We have found that the considerable effort invested in trying to improve duration of breast feeding amongst women in Australia appears to have failed to improve sustained breast-feeding rates. We argue that this situation might be related to losing sight of the embodied nature of breast feeding and the relationships that must exist between the mother and baby, the knowledge and skills women quickly develop, and a loss of woman to woman support. We conclude that midwives have a major role in avoiding us reproducing similar, unintended, negative consequences to those resulting from increasing obstetrician managed normal birth. These include midwifery scrutiny and involvement in policy development and institutional practices and the design of services., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Young males have a key role in shaping contraceptive use in a sexual relationship, yet often remain the invisible partner in safe sex promotion. This article describes a conceptual model of STI risk and condom use based on the perceptions and experiences of condom use in a group of young Australian males. An explorative descriptive design was used to conceptualize participants' condom use histories into an organized description of behavior. Forty-two semi-structured interviews were conducted with a purposive sample of males aged 15 to 25 years over an 18 month period. A sequential analytical process of data immersion, coding, and category generation was used to identify personal meanings, motivations, and contextual factors associated with condom use and non-use. Three primary discourses associated with young males' perceptions of STI risk and responding approach to condom use constructed personal commitment to sexual safety as dynamic, context-dependent, and outcome-driven (pregnancy versus STIs as the primary motivator of condom use). A regretful discourse associated with experiences of, or suspected unwanted outcomes, also emerged through changes in risk appraisals and safe sex intentions and behavior. Interventions to increase condom use should go beyond the traditional focus on risky behavior and disease prevention frameworks by addressing the contextual influences on personal risk appraisals and deliver innovative messages to reduce negative social meanings associated with condom use.

Aim: To explore and describe men's experiences of pregnancy and childbirth expectations., Background: There remains limited work exploring expectant father's perspectives., Design: Qualitative descriptive design. Twelve Australian expectant fathers participated in between 1 and 2 interviews during pregnancy and 1 after childbirth (32 in total). Six fathers also chose to submit a number of diary entries via e-mail. Thematic analysis was used to analyse the data set., Findings: Five themes emerged from the data. The themes pregnancy news: heralds profound change adjusting to pregnancy, and birth looming described how men processed the news of pregnancy, worked to accept their changed circumstances and negotiated the final week of the pregnancy. A fourth theme, labelled Feeling sidelined, outlined men's experiences of antenatal care and their feeling of isolation as a result of largely feeling ignored by health care professionals. The fifth theme represents men's childbirth expectations., Conclusion: Adjusting to the news of a pregnancy was a potentially unsettling time for an expectant father that was often associated with increased apprehension and anxiety. Regardless of whether they were a first or once again father most men engaged in a level of emotional work to come to terms with and accept the pregnancy. Understanding men's antenatal experiences and anxieties is an important step in the development of preventative paternal perinatal mental health measures. The significance of this work is situated within the reality that men's wellbeing is associated with maternal psychological well-being, positive peri-natal experiences and child development., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Aims and Objectives: To identify the expectations and workforce intentions of new graduate midwives from two different pre-registration educational courses at one Australian university., Background: In Australia there are two different educational pathways to midwifery qualification, one offered for registered nurses, commonly at a postgraduate level and the other for non-nurses, at an undergraduate level. The knowledge about midwifery graduates in general is reasonably limited and there is no specific research that examines the similarities and differences between graduates from the two different courses., Design: A cross-sectional design was used., Method: Data were collected by questionnaire from both undergraduate and postgraduate midwifery graduates in 2007 and 2008 at one Australian university. Data were analysed using descriptive statistics., Results: Almost all the graduates from the two different pre-registration courses intended to enter the midwifery workforce with both groups rating the factors that influenced this decision similarly. There were, however, significant differences in graduates age and their intention to work part time. Their views of their ideal roles and subsequent uptake into formal new graduate transition programmes differed. Graduates from the two courses also reported philosophical differences regarding their concepts of job satisfaction and ways their jobs could be improved., Conclusions: The graduates from the two different courses showed sufficient significant differences to warrant consideration in current workforce planning for midwifery., Relevance to Clinical Practice: The factors that influence the career decisions of new graduate midwives can positively impact educational and workforce planning. The findings may be able to help inform strategies to address turnover and attrition in midwifery., (© 2011 Blackwell Publishing Ltd.)

Despite considerable evidence and effort, breastfeeding duration rates in resource-rich countries such as Australia remain below World Health Organization recommendations. The literature on the experience of breastfeeding indicates that women construct and experience breastfeeding differently depending upon their own personal circumstances and the culture within which they live. Breastfeeding has also been described as a deeply personal experience, which can be associated with 'moral' decision-making. The aim of this synthesis was to better understand the social phenomenon of breastfeeding by making the hidden obvious. Using a meta-ethnographic approach, we analysed the findings from 17 qualitative studies exploring women's experience of breastfeeding. Commonly used metaphors, ideas and phrases across the national and international qualitative studies were identified. Two overarching themes emerged. Breastfeeding was described in terms of 'expectation' and 'reality', while the emotional aspects of breastfeeding were expressed in 'connected' or 'disconnected' terms. The prevalence of health professionals and public health discourses in the language women use to describe their experience, and the subsequent impact of this on maternal confidence and self-assessment of breastfeeding are discussed. This synthesis provides insight into some of the subtle ways health professionals can build maternal confidence and improve the experience of early mothering.

Objectives: to describe Australian midwives' experiences of an external review of obstetric services, involvement in legal proceedings and the impact on midwives' clinical practice and personal wellbeing., Background: the external review process (commonly referred to as the 'Douglas Inquiry') was initiated by a state government and was in response to hospital staff and consumer complaints that focused on anomalies in client care and a significantly high rate of adverse outcomes and clinical errors. It took place within the context of a number of legal proceedings against medical practitioners. As a result, some midwives employed by the hospital were called to give evidence at a variety of legal forums., Design: a qualitative study using an explorative descriptive design. Snowball sampling was used to invite 16 Australian midwives to participate in a tape-recorded interview. Thematic analysis and the techniques associated with constant comparison were used to analyse the data., Setting: Australian maternity tertiary referral centre., Findings: the analysis identified two overarching themes, 'A story of scrutiny' and 'A story of fear', each with a number of subthemes. 'A story of scrutiny' consists of three subthemes. 'A cloak and dagger affair' reflects the midwives' sense of being and feeling 'exposed' and 'vulnerable' whilst simultaneously being 'kept in the dark' and uninformed during the review process. The subtheme 'Being thrown to the wolves' describes the midwives' experiences of being involved, as witnesses, in medico-legal proceedings. The third subtheme, 'The Inquiry followed them home' outlines the effect on midwives' emotional wellbeing and personal relationships. The second major theme, 'A story of fear' again consists of a number of subthemes. 'Feeling unsafe at work: a culture of fear' describes the midwives' experiences of working within an environment they perceive as driven by the fear of litigation. In order to protect themselves and maintain a sense of control, the midwives adopted a number of strategies to 'feel safe' including defensive decision making and moving towards a medical philosophy of care. These concepts are captured within the subtheme 'Covering your back: setting boundaries'. The impact on relationships between midwives, women and medical practitioners is described within the subtheme 'Professional relationship: coloured by fear'. The effect on midwives' confidence and the resultant negative emotions elicited make up the subtheme 'Between a rock and a hard place: the midwives' distressing dilemma'. Finally the subtheme, 'Opting out: the changing nature of professional work practices' describes the specific professional decisions and work strategies that midwives made about their ability to continue working in an environment that they perceived as threatening., Conclusion: the findings suggest that the midwife participants in this small study were totally unprepared and ill equipped, both personally and professionally, to deal with the consequences of working within an environment that was the centre of a number of high profile legal proceedings and an extensive external review of obstetric services. The midwives were naïve about legal processes and unprepared for the legal 'game playing' and media attention that often accompanies court proceedings. Despite the fact that no midwife faced litigation, the participants described their work environment as becoming increasingly stressful and permeated by a culture of fear. In turn, this situation has reinforced the need for some midwives to adopt an 'institution' ideology which reinforces birth as an abnormal event that needs to be medically managed. This has led to changes in professional and personal work practices. The findings also have implications for the midwifery workforce and retention. Although the findings are context specific, this study provides valuable insight into the phenomena of fear of litigation and its impact on midwifery practice. Given the similarities concerning obstetric litigation in some other Western nations, the findings have relevance in the international midwifery arena., (Copyright 2008 Elsevier Ltd. All rights reserved.)

Purpose: To better understand the factors that influence the initiation of first intercourse among adolescent females and to explore the context in which this occurs., Methods: A purposive sample of sexually active female teenagers aged between 14 and 19 years were recruited from sexual and reproductive health clinics across the Perth metropolitan area. Sixty-eight in-depth, semistructured interviews were conducted. Thematic analysis was employed to analyze the narrative data. Meanings and interpretations that emerged were constantly verified through subsequent inquiry., Results: The degree of personal control over the factors that led to their first experience of intercourse determined how teenagers reflected upon the experience. Those who were "ready" were more likely to have delayed intercourse until they were comfortable with both when and with whom this occurred. In contrast, conforming to peer norms, coercion from sexual partners and being intoxicated were common reasons for premature and unwanted first experience of sexual intercourse., Conclusions: The explorative approach used in this study deepens current understanding of the factors influencing and associated with intercourse initiation, and how these reflect different aspects of adolescent development. In particular, the role of young peoples' sociocultural environment, including peer interaction and alcohol intoxication, alongside pressure from sexual partners in premature and unwanted sexual activity may assist in informing educational interventions of greater personal relevance and impact.

Aim: The aim of the study was to increase knowledge and understanding of how women begin their roles as mothers when their infant is in the neonatal nursery., Background: Research is limited into how women experience mothering in contexts such as the neonatal nursery. Consequently many nurses and midwives remain inadequately informed of parents' experiences which we know may have long-term family outcomes., Method: This paper presents the overarching synthesis of a grounded theory analysis of data collected from 28 Australian women whose infants were in Special Care Nurseries. It draws together a number of previous publications that have described in detail the categories derived from the analysis that explain the actions, interactions and reactions women engage in as they seek to 'connect' with their infant. Data collection consisted of two in-depth interviews conducted with women, 333h of taped cot side recordings, field notes and interview data collected from 20 nursery staff, 19 of whom were midwives., Findings: Six major categories were identified that, when combined, explained the intense emotional, cognitive and worry 'work' women undertook with both their infants and the nursery staff in an effort to learn how to mother in the nursery. Four explained how women worked to get to know and connect with their infants. The first three were labelled 'just existing', 'striving to be the baby's mother' and 'trying to establish competence'. The fourth, 'learning and playing the game', overlays the first three and represents the reality of having to undertake these already difficult and unexpected activities of mothering in the nursery. Two categories 'becoming connected' and 'struggling to mother' were identified as the consequences of women's actions and interactions. A significant finding of the study was the impact of the interactions between nurses and mothers' mothering. The nurse-mother relationship had the potential to significantly affect how women perceived their connection to the infant and their confidence in caring for their infant which occurred through a three way interaction., Conclusions: It becomes clear that the intense work women undertake as mothers in the nursery is focused on not only the infant, which might have been expected, but also the nursery staff. It is driven by their desire to develop or re-establish some sense of competence in the eyes of the nurse and to achieve control over the situation. Achieving physical closeness with the baby was a major strategy through which women not only learned about and gained intimate knowledge of their infant, but also demonstrated authority and ownership. It appears that reorientating the delivery of services from the infant to the mother-infant dyad would improve the care women and families receive during their nursery experience.

This paper reports on one aspect of a grounded theory study of women's experiences of mothering in the nursery. Over 60 hours of interview data with 28 Australian women were analyzed. The analysis revealed that mothering in the nursery was a three-way interaction. "Struggling to mother" was the label given to the major category that represented how women responded to unsatisfactory nursing encounters. The findings illuminate how inhibitive nursing interactions relegate women to the periphery of care and engender an array of negative emotional responses that leave women feeling inconsequential to the welfare of their infant. Ultimately this has implications for how women take up their role as mothers in the nursery and for their sense of confidence, competence, and connection with their infant.

Aim: This paper explores the use of 'chat' or 'social talk' as an important clinical tool that can assist nurses achieve family-centred care in neonatal nurseries., Background: The study was undertaken to increase knowledge of women's experiences of mothering in the neonatal nursery and the relationship they share with nurses., Method: The discussion presented is elicited from a grounded theory analysis of over 60 hours of interview data with 28 women, a thematic analysis of 50 hours of interviews with 20 nurses and a content analysis of 398 tape-recorded interactions between nurses and parents., Findings: The analysis identifies the importance of the nurse-mother relationship and demonstrates that it is both the context and method by which nursing care is delivered. We found the verbal exchanges that take place between nurse and mother influence a woman's confidence, her sense of control and her feelings of connection to her infant. It appears from the data that the nurse's ability to effectively 'engage' the mother is dependent on the use of language that expresses care, support and interest in parents., Conclusions: The data suggests that 'chatting' is the strategy and the process through which positive interactions are initiated, maintained and enhanced. This study confirms that nurses' language acts as a powerful clinical tool that can be used to assist parents in gaining confidence in caring for their infants and in becoming 'connected' to infants resident in nurseries.

This article reports an ethnographic study that examines the context and nature of the interactions between health professionals and parents in two Australian level II nurseries: 724 observations were recorded over an 18-week period. Analysis revealed that although the presence of mothers in the nursery was high, registered nurses remain the primary caretakers of the infants. The interactions between registered nurses and mothers were found to be action- or task-oriented with communication largely being described as "instrumental." The results of this pilot work suggest that the emphasis of clinical practice in level II nurseries remains focused on caring for the infant and teaching the mother. This is in contrast to the current body of literature that identifies the need for a family-centered approach to care that aims to support parents as they develop confidence, attach to their baby, and become skilled in providing care themselves.