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Problem: Globally medical management of labour and birth has significantly increased, with epidurals attributed to the cascade of interventions., Background: There are few randomised control trials that evaluate the effectiveness of antenatal education programs. A previous trial at two Australian hospitals found an antenatal program of integrative complementary therapies significantly reduced rates of interventions for low-risk primiparous women., Aim: To reduce rates of intervention in labour and birth, with a primary outcome of decreased epidural use during labour., Methods: Low to moderate risk primiparous women were randomised at 24-36 weeks' gestation to the intervention group and standard care, or standard care alone. Clinical and psychological measures were analysed by intention-to-treat. Trial registration ACTRN12618001353280 FINDINGS: In total, 178 women participated (n = 88 intervention, n = 90 Standard care), demographic characteristics were similar between groups, almost half (49 %) reported a pre-existing medical condition, and wellbeing scores fell within the average range. Epidural use was lower in the intervention group (47.7% vs 56.7 %) with higher rates of vaginal birth (52.3% vs 42.2 %), however, no statistical differences for birth outcomes were found between groups. Attitude to childbirth scores were statistically higher for women who attended the intervention (59.1 vs 54.3 p00.001)., Discussion: Higher psychometric scores demonstrated women in the intervention group felt an increased sense of coping and control. Antenatal education that includes complementary therapies can reduce fear and improve attitudes about childbirth., Conclusions: Replicating study protocols enabled the generalisability of findings to a more diverse group of women, and data will contribute to a larger meta-analysis design to detect smaller treatment effects for operative birth., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To identify what is currently known about how women experience online antenatal education., Design: Integrative literature review., Review Methods: This integrative review applied the five-stage methodological framework outlined by Whittemore and Knafl (2005), supporting rigour in problem identification, selection and critical appraisal of quality literature, data analysis and synthesis of findings., Data Sources: A literature search was conducted in May/June 2022, utilizing databases including OVID Embase, CINAHL, Joanna Briggs Institute EBP database, Nursing and Allied Health database, Wiley Online Library, Google scholar search engine and related reference lists. The search was limited to English language and primary research articles published in the last 10-year period (2012-2022)., Results: 12 articles met inclusion criteria. Three primary themes were identified: Comprehensibility: Looking back - understanding women's needs and preferences; Manageability: In the moment - flexibility versus social connection; and Meaningfulness & sustainability: Looking forward - the future of digital maternity education., Conclusion: Findings identified a marked digital divide for women accessing online antenatal education, placing vulnerable women at risk of continuing inequity. E-health literacy frameworks need to be implemented to create genuine accessibility, comprehensibility and cultural responsiveness to best meet the needs of users., Implications for the Profession And/or Health Care Consumer: As digital health is an emerging field, there is strong evidence that online antenatal education requires further evaluation to better meet the needs of pregnant women and their support people. Enhancing digital health literacy for health professionals will also promote a greater understanding for how to uphold and support the socio-technical dimensions of online service delivery., Patient or Public Contribution: There were no patient or public contributions as part of this integrative review of the literature., (© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Background: Moral distress is a phenomena that occurs following a compromise to moral beliefs. Moral distress has been reported across health professions, including midwifery. Although there are validated tools to assess for moral distress, none have been identified that suit the Australian healthcare system or midwifery., Aim: The aim of this study was to pilot the Barometer of Moral Distress in Midwifery., Methods: This study was the fourth stage of a mixed method project. Using a cross-sectional approach, a survey tool including demographic questions, the Barometer of Moral Distress in Midwifery, and the Copenhagen Burnout Inventory assessed tool stability, reliability, and validity., Findings: A total of 103 surveys were completed. A test-retest demonstrated tool reliability and stability (a =.97). Factor analysis confirmed internal consistency; Factor 1 - Professional Identity (a=.91), Factor 2 - Inadequate Resources (a=.85), and Factor 3 - Unethical Cultures (a=.88). Concurrent validity was demonstrated through positive correlations between self-reported types of moral distress with mean scores for each Factor. Strong correlations were identified between work-related burnout and mean scores, while only weak correlations were noted between client-related burnout and mean scores. Only Factor 1 demonstrated a correlation between leaving the profession and mean scores., Discussion/conclusion: This was the first moral distress tool that assessed both frequency of exposure and psychological outcomes to score moral distress. Findings indicate that moral distress in midwifery is not associated with caring work but with occupational environments. Further research is required to assess self-sacrifice in moral distress., Competing Interests: Conflicts of interest Conflicts of interest to be declared include Professor Linda Sweet who is Deputy Editor for Women and Birth and Associate Professor Lois McKellar who is on the editorial board. Neither had have any part in the review process of this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: In the past 30 years, 60% of South Australia's rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken., Objective: The study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers., Design: The evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services., Findings: The first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the 'MMoC was working well.' The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that 'there is no other option - it has to work'., Discussion: All participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals., Conclusion: This innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is 'no other option-it has to work'., (© 2023 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Problem: Research on how women experience online antenatal education is currently limited. A more nuanced understanding may assist organisations to tailor future digitalisation that best meets the needs of users., Background: COVID-19 emergency measures forced a rapid implementation of online antenatal education. Women are known to enjoy some aspects of online antenatal education, but still desire social interaction. A marked digital divide is evident for more vulnerable populations., Aim: To explore how pregnant women experience an online antenatal education program., Methods: A descriptive exploratory study was undertaken through collection of two concurrent data-sets. Quantitative data was collected from the online Parent Education Feedback Form (n = 38) Based on the six-stage process of Braun & Clarke, reflexive thematic analysis was used to analyse data sourced from semi-structured interviews with women (n = 5) who had undertaken online antenatal education., Findings: Four themes, and eight associated sub-themes, were identified to better understand how women experience online antenatal education. The four primary themes identified were: Experiential Digital Learning; Desired Journey; Contemporary Representation; and Human Connection in the Digital Age., Discussion: Well-designed digital platforms provide opportunities for interaction, content personalisation and self-tailored approaches in online antenatal education. Women require caregivers who hold specialist digital capabilities. Further research is warranted to better understand how digitalisation of antenatal education impacts women disadvantaged by digital exclusion., Conclusion: The digital transformation of antenatal education impacts a vast array of factors in women's experiences during pregnancy. A specialist skill-set from midwives is needed to champion quality antenatal education in the digital age., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Global migration has seen an increase in female genital mutilation/cutting (FGM/C) cases observed in countries where it is not part of the cultural norm. This shift has led to many healthcare professionals (HCPs) reporting a lack of knowledge and skills necessary to support the needs of women with FGM/C., Aim: To explore the experiences and needs of women with FGM/C accessing women's health services in South Australia., Methods: Women with FGM/C were recruited through purposive and snowball sampling to participate in one-to-one semi-structured interviews. The voice recorded interviews were transcribed verbatim, coded, and analysed using Braun and Clarke's reflexive thematic analysis to determine themes., Findings: Ten migrant and refugee women living in South Australia, were interviewed. Four themes and 13-subthemes were identified. The main themes were, 1) the healthcare experience, 2) cultural values shape the healthcare experience, 3) speaking up about female genital cutting and 4) working together to improve healthcare experiences., Discussion: Women's cultural needs, not their health needs, play a fundamental role on how women experienced healthcare services. When women's cultural values and traditions are acknowledged by HCPs, they are more likely to trust and feel confident to engage with services and seek medical support. Areas identified for improvement included access to the right interpreters, having more time during appointments, opportunities for continuity of care and the inclusion of family in care and treatment decisions., Conclusion: Women with FGM/C have specific health and cultural needs that can be met through education and provision of woman-centred care., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Moral distress is a psychological concept that describes the harm associated with actions or inactions that oppose an individuals' moral beliefs. Moral distress is linked to moral compromise in the workplace that may negatively impact mental wellbeing. Current tools available to assess moral distress are not specific for the Australian health care system or midwifery practice., Aim: The aim of this study was to develop a list of situational and outcome statements associated with moral compromise and levels of moral distress in midwifery to inform the development of a tool to measure levels of moral distress in midwives., Methods: This e-Delphi study was the third stage of a sequential exploratory mixed-methods study. Using an online strategy, three iterative rounds of e-Delphi were collected and analysed for consensus on situations leading to moral distress and the associated psychological outcomes., Findings: Twenty participants contributed across the three rounds. Consensus was met in 40 morally compromising situation statements. The highest level of consensus related to excessive workloads and the associated negative impact of this on women and families. Consensus on outcomes following exposure to morally distressing situations led to the development of a continuum scale from moral frustration to moral injury., Discussion/conclusion: This is the first study to use a consensus method to establish different levels of moral compromise, frustration, distress, and injury in midwifery practice. The findings of this study contribute to a growing body of literature that supports the concept of moral distress occurring across a continuum., Competing Interests: Conflict of Interest Professor Lois McKellar and Professor Linda Sweet have editorial duties with this journal. To reduce any real or perceived conflict of interest, they had no role in the processing or peer review of this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: A plethora of research has identified the lack of educational opportunities for health professionals to support the biopsychosocial and cultural needs of women who have experienced female genital mutilation/cutting (FGM/C). As a result, some women with FGM/C can feel unsupported, discriminated against and fear to communicate their concerns with health providers. The aim of this review is to identify studies that have investigated the effectiveness of FGM/C education for health professionals., Method: Toronto and Remington's six-step framework for conducting an integrative literature review was used to identify studies that met the inclusion criteria. Searches were conducted across five primary databases and grey literature, between August and October 2021. The Joanna Briggs Institute critical appraisal tools for quasi-experimental studies was used to critically appraise included studies. The findings of the search were reported using preferred reporting items for systematic reviews and meta-analysis., Results: A total of five studies met the criteria for inclusion. Studies examined education provided to midwives, nurses, obstetricians, gynaecologists, psychosexual counsellors and student nurses, from England, USA, Mali and Kenya. All studies demonstrated that the implementation of FGM/C education was effective in improving learning outcomes (knowledge, attitude and self-efficacy), However, the quality rating of the evidence ranged from very low to moderate and limited inferential analysis reported., Conclusion: This review confirms that FGM/C education, which is informed by evidence and developed in collaboration with practicing communities, is an effective way of improving FGM/C knowledge and attitudes among health professionals., Study Registration: Open Science Framework Register 10.17605/OSF.IO/SMJHX., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Problem: While literature reports broadly on the experiences of international students of health professions in higher education, the experience of students undertaking an undergraduate midwifery program outside their country of origin has not previously been reported., Background: Midwifery studies incorporate distinct clinical practice and discipline-specific therapeutic relationships which can challenge students familiar with the health system, so it is necessary to understand their impact on the learning needs of international students, who contribute to the diversity of our workforce., Aim: To explore learning experiences of international students of an undergraduate midwifery program to identify their perceptions and personal strategies which impacted their participation in the program., Methods: A qualitative descriptive study, with a purposive sample of nine current international students and recent graduates of a midwifery program at a South Australian university. Participants attended a focus group or individual phone interview to explore their learning experiences, and data were thematically analysed., Findings: Five themes and sub-themes were identified, built around a core concept of the international midwifery student experience as agency in change: language and culture, teaching and learning, isolation and integration, services and support, and motivation and resilience. Studying abroad was associated with personal and professional growth. Continuity of care for women presented challenges and produced learnings unique to this cohort., Conclusion: Tailored support, such as specialized clinical facilitation and organized peer networking, is required for international midwifery students in Australia. Additionally, effective approaches to facilitate bilingualism to support language concordant care are needed., Competing Interests: Conflicts of interest None., (Copyright © 2022 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Integral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions., Aim: To critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia., Methods: A structured integrative literature review using Whittemore and Knafl's five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results., Findings: The literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education., Discussion: Extensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality., Conclusion: There is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: The ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women's experiences and birth outcomes., Aim: To evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care., Method: An anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included., Findings: The response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6-8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes., Conclusion: This innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators., Competing Interests: Declaration of Competing Interest We have no conflicts of interest to declare. A/Professor Lois McKellar is on the editorial board of Women and Birth., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Problem: Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice., Background: Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals' moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice., Aim: To explore Australian midwives experience and consequences of moral distress., Methods: Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©., Findings: Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care., Discussion: It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding., Conclusion: This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Female genital mutilation/cutting (FGM/C) is a complex and deeply rooted sociocultural custom that is innately entrenched in the lives of those who continue its practice despite the physical and psychological dangers it perpetrates. FGM/C is considered a significant independent risk factor for adverse maternal and fetal outcomes in pregnancy and childbirth. Several studies in high-income countries have explored the experiences and needs of women with FGM/C as well as the knowledge of the health professionals, particularly midwives and nurses, who care for them. However, to date, no studies have evaluated the implementation of education for health professionals in high-income countries to meet the specific needs of women with FGM/C., Objective: This study aims to explore the impact of an FGM/C education program for midwives and nurses as informed by the experiences of women with FGM/C accessing maternity, gynecological, and sexual health services in South Australia., Methods: This study will adopt a three-phase, exploratory sequential mixed methods design. Phase 1 will involve the exploration of women with FGM/C views and experiences accessing maternity and gynecological (including sexual health) services in South Australia. The findings from phase 1 will inform phase 2: the development of an educational program for midwives and nurses on the health and cultural needs of women with FGM/C. Phase 3 will involve the evaluation of the program by measuring midwives' and nurses' changes in knowledge, attitude, and practice immediately before and after the education as well as 4 months after completing the program. Phase 1 of this study has been approved by the Women's and Children's Health Network human research ethics committee (ID number 2021/HRE00156) and the University of South Australia human research ethics committee (ID number 204096)., Results: Phase 1 will commence in August 2021, with the interpretation of findings being undertaken by November 2021. Phase 2 will be developed and facilitated by February 2022, and the final phase of this study will begin in March 2022. This study is expected to be completed by February 2023., Conclusions: The findings of this research will provide insight into the development and evaluation of education programs for midwives and nurses that includes collaboration with women from culturally and linguistically diverse backgrounds to address the specific cultural and health needs of communities., International Registered Report Identifier (irrid): PRR1-10.2196/32911., (©Monica Pilar Diaz, Mary Steen, Angela Brown, Julie-Anne Fleet, Jan Williams. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 15.10.2021.)

Background: From the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established., Aim: To better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future., Methods: Semi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis., Findings: Three overarching themes and several sub-themes were identified, these included: 'Midwifery suffragettes' which explored 'activism', 'adversity' and 'advocacy'; 'Building bridges' captured the importance of 'gathering midwives', a 'movement of women' and 'champions and influencers'; and 'Recognising midwifery' identified the strong 'sense of identity' needed to outface 'ignorance and opposition' and the importance of 'role reformation'., Conclusion: These midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change., Methods: A descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant's commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey., Results: Overall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12-60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, "People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements "People who work here are determined to implement this change", "People who work here want to implement this change", and "People who work here are committed to implementing this change., Conclusion: Results of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies.

Globally, education continues to diversify, with a growing body of literature that describes the experiences of international higher education students. While the research includes representation from the health sciences, nursing and midwifery programs are underrepresented; understanding the experiences of international students therein may assist in determining whether discipline-specific teaching, learning and support is required. This review aims to summarise international nursing and midwifery students' perceptions of challenge and enablement when undertaking an undergraduate or baccalaureate program. A total of 408 articles were identified and after duplicates were removed and inclusion/exclusion criteria applied, eight primary studies were included. No papers were identified that reported on the experiences of international midwifery students. For international nursing students, five themes emerged: language and culture, isolation and segregation, teaching and learning, services and support, and resilience and growth. This review concludes that the available data both affirms the existing body of knowledge around international students and illuminates unique challenges and opportunities for nursing students undertaking clinical placements. There is a need for increased language and peer support, socialisation and specially educated support staff. Research is required to identify best practice in teaching methodology for an increasingly diverse cohort and importantly, to provide a midwifery perspective., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Birth Centres (BC) are underpinned by a philosophy of woman- centred care and were pivotal in growing models of midwifery-led care in South Australia (SA)., Aim: To describe BC utilisation and the growth of midwifery-led care in SA over the past two decades., Methods: The SA Perinatal Statistics Collection was used to describe women birthing from 1998 to 2016. Number of births through midwifery-led services from 2004 to 2016 were obtained from unit managers. Analyses are descriptive., Findings: Women who birthed in BC in SA from 1998 to 2016 comprised approximately 6% of all births per year, and numbers have remained static. Three BC models operate in SA, all with different capacity. Proportionally, women not born in Australia are as likely to birth in BC as labour wards. The proportion of women who received midwifery-led care (whether affiliated with a BC or not), increased from 8.3% in 1998 to 19.2% of all births in 2016. Of the women who received midwifery-led care in 2016, 15.3% went on to birth in a midwifery-led model of care., Conclusion: Whilst the overall number of BC births has not increased, women seeking midwifery-led care has more than doubled over the past two decades. BC encompass the midwifery philosophy, quality of care, and a physical home-like environment. The BC models in SA are managed through the three tertiary maternity units enabling women to access publicly funded midwifery care and should be more widely available., (Copyright © 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Introduction: Midwives have an important role in providing education in healthy eating to pregnant women, which is essential for maternal and foetal health and wellbeing. Importantly, midwives require continual professional development to ensure they provide up-to-date education., Methods: A pre-post intervention study utilised a purpose-designed questionnaire to collect data at three time points. Forty-four midwives completed the pre education questionnaire, 29 of these midwives attended the education intervention (workshop/webinar) and completed the immediately after questionnaire. Nineteen midwives then completed a questionnaire at 6-8 weeks follow-up. The study aimed to evaluate midwives' knowledge and level of confidence to discuss healthy eating in pregnancy., Results: Education in healthy eating improved midwives' knowledge and level of confidence, which were maintained for six to eight weeks. The mean difference of total scores on knowledge and confidence between pre and immediately after education questionnaires showed a statistically significant improvement in nutrition knowledge (4.93 ± 1.62 vs 7.55 ± 1.55; p<0.001) and confidence level (22.05 ± 6.87 vs 31.48 ± 7.47; p<0.001). In terms of the mode of education, there was a significant increase in total knowledge scores for midwives who attended a workshop compared to a webinar., Conclusions: Overall, healthy eating education improved midwives' knowledge and confidence immediately after receiving education and also at 6-8 weeks follow-up. This study is unique as it evaluated midwives' knowledge and level of confidence at 6-8 weeks post education. This study concludes that midwives benefited from receiving further knowledge on cultural food choices, eating behaviours, and dental care., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. S. M. E. Othman reports a scholarship from The Cultural Affairs and Mission Sector, Ministry of Higher Education of the Egyptian government during the conduct of the study., (© 2020 Othman S. M. E. et al.)

Background: The effect that the route of maternal fentanyl administration has on placental transfer of drug to the neonate is not well studied. Plasma concentration ratios are an indicator of fetal exposure, relative to the mother., Methods: A cohort study (n=30) was conducted to measure fentanyl concentrations in maternal plasma, and arterial and venous cord blood, among women administered either intranasal or subcutaneous fentanyl for labour pain relief. Maternal and cord blood samples were collected within 30 min of birth to determine the fentanyl plasma concentration and to assess relative neonatal exposure. Neonatal outcomes were assessed by Apgar scores, need for resuscitation and nursery admission., Results: Thirty paired samples were obtained from healthy parturients with uncomplicated term pregnancies. Highest observed umbilical venous and arterial concentrations were 0.71 ng/mL and 0.56 ng/mL, respectively, and fetal to maternal fentanyl plasma concentration ratios ranged between 0.23 and 0.73, indicating low fetal exposure. While the total intranasal fentanyl dose administered was significantly higher than the subcutaneous fentanyl dose, this did not result in a higher fetal to maternal ratio. All neonates in both groups had 5-min Apgar scores >7, two neonates required short-term stimulation and oxygen (unrelated to fentanyl) and no neonate was admitted to the nursery., Conclusion: This study is the first to examine fetal and maternal fentanyl concentrations after subcutaneous administration. This research supports the safe use of fentanyl for labour analgesia for women., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: This study aimed to identify the way information is described and presented by childbirth educators during antenatal classes for expectant parents, and analyse the language structures used when discussing labour and birth., Methods: This cross-sectional study of antenatal education was conducted at a single tertiary referral centre for Maternity Care in Western Sydney, Australia. All childbirth educators (n=3) were recorded whilst providing information to parents during antenatal classes. Audio data were subsequently transcribed and then analysed by two researchers, independently categorising the various language structures and types of information provided. This is the second study in a series of antenatal education topics., Results: During the labour and birth class, information statements were the predominant language structure that was spoken with 241 of 655 statements; negative statements were the next most frequent at 119 while there were 79 positive statements. The second stage of labour had a greater proportion of negative statements for two educators, followed by information and positive statements combined. Misinformation statements were minimal for this topic however, and there was an absence of any statements discussing the rest period between contractions., Conclusions: The findings further emphasise the need to examine the language used by health professionals when educating parents. Negative statements during antenatal education are still common despite research in other contexts suggesting that these are potentially unhelpful. Further research into the language and suggestions used during antenatal education is required to determine whether improved outcomes seen in other contexts are confirmed in the childbirth setting., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2020 Cutajar L. et al.)

Background: Biomedical research in the application of noncontact methods to measure heart rate (HR) and respiratory rate (RR) in the neonatal population has produced mixed results. This paper describes and discusses a protocol for conducting a method comparison study, which aims to determine the accuracy of a proposed noncontact computer vision system to detect HR and RR relative to the HR and RR obtained by 3-lead electrocardiogram (ECG) in preterm infants in the neonatal unit., Objective: The aim of this preliminary study is to determine the accuracy of a proposed noncontact computer vision system to detect HR and RR relative to the HR and RR obtained by 3-lead ECG in preterm infants in the neonatal unit., Methods: A single-center cross-sectional study was planned to be conducted in the neonatal unit at Flinders Medical Centre, South Australia, in May 2018. A total of 10 neonates and their ECG monitors will be filmed concurrently for 10 min using digital cameras. Advanced image processing techniques are to be applied later to determine their physiological data at 3 intervals. These data will then be compared with the ECG readings at the same points in time., Results: Study enrolment began in May 2018. Results of this study were published in July 2019., Conclusions: The study will analyze the data obtained by the noncontact system in comparison to data obtained by ECG, identify factors that may influence data extraction and accuracy when filming infants, and provide recommendations for how this noncontact system may be implemented into clinical applications., International Registered Report Identifier (irrid): RR1-10.2196/13400., (©Kim Gibson, Ali Al-Naji, Julie-Anne Fleet, Mary Steen, Javaan Chahl, Jasmine Huynh, Scott Morris. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 29.08.2019.)

Background: Nutrition and healthy eating behaviors during pregnancy are vitally important for the health of a mother and her developing baby. However, some midwives have reported a lack of evidence-based nutrition knowledge for providing information about healthy eating to women during pregnancy., Objective: In this study, the aim is to design and evaluate a healthy eating education program to enhance midwives' knowledge, understanding, and confidence to support pregnant women in South Australia to make healthy eating choices., Methods: This mixed-methods study consists of two phases. The first phase, Phase 1, consists of an education program for midwives, "Healthy Eating in Pregnancy," to be delivered through a workshop or webinar. Each midwife will attend one workshop or webinar, which will be approximately two hours in length. This program will be evaluated through pre-, immediate-, and post-educational questionnaires utilizing a website specifically designed for this study. The participants will be midwives who are members of the Australian College of Midwives and the Australian Nursing and Midwives Federation, and users of social media (eg, Facebook and Twitter) residing and employed in South Australia. Phase 2 will consist of semistructured interviews with a purposive sample of midwives. These interviews will be undertaken to gain an in-depth understanding of midwives' views and how confident they feel educating pregnant women after receiving the healthy eating education. Interviews will be face-to-face or conducted by telephone with midwives who have participated in the healthy eating educational program., Results: A systematic review has previously been undertaken to inform this study protocol. This paper describes and discusses the protocol for this mixed-methods study, which will be completed in April 2019., Conclusions: The results from the systematic review suggest that there is clear justification to undertake this mixed-methods study to investigate and explore midwives' knowledge, understanding and confidence to support healthy eating in pregnant women. The results and conclusions from the systematic review provided some guidance for the design and development of this study protocol. This mixed-methods study will address a gap in the literature. The results from quantitative and qualitative data sources in this proposed study will help to draw conclusions to address the research topic., Registered Report Identifier: RR1-10.2196/9861., (©Shwikar Mahmoud Etman Othman, Mary P Steen, Rasika Jayasekara, Julie-Anne Fleet. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 25.05.2018.)

Objective: To compare women's experience of receiving either intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for labour analgesia., Design: A content analysis was undertaken as part of the third phase of a larger randomised controlled trial, using the per-protocol dataset to examine women's experiences of treatment received. Healthy women birthing at term, who received intranasal fentanyl (n=41), subcutaneous fentanyl (n=37) and/or intramuscular pethidine (n=38) for labour analgesia, were contacted at 6 weeks postpartum to complete a phone questionnaire., Setting: A tertiary and regional maternity unit in South Australia., Findings: Over 80% of women who received intranasal or subcutaneous fentanyl reported that they would use the treatment again compared to 44.8% of women who had received pethidine (self-administered intranasal fentanyl provided more expressive responses emphasising the route provided a strong sense of control and enablement., Key Conclusions: Route of administration influenced the women's experience, more women who self-administered intranasal fentanyl reported positive emotional responses, with women reporting increased autonomy and satisfaction. Whereas, women who relied on the midwife to administer subcutaneous fentanyl or intramuscular pethidine, were more often focused on the physical effect of the drug. Pethidine was the least preferred option due to adverse effects., Implications for Practice: For women requesting parenteral analgesia, fentanyl administered by less invasive routes offers women additional options that may better meet their emotional, cognitive and physical needs than the current practice of administering intramuscular pethidine., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To examine breastfeeding experiences up to 6 weeks postpartum for mothers administered intranasal fentanyl, subcutaneous fentanyl or intramuscular pethidine for intrapartum analgesia., Design: A secondary analysis was undertaken using the per-protocol dataset to examine the third phase of a larger randomised controlled trial. This phase of the study examined breastfeeding intention and experience from the first hour of birth to 6 weeks postpartum. Medical records were audited and women were contacted at 6 weeks postpartum to complete a telephone questionnaire., Setting: Two maternity hospitals in South Australia., Participants: Healthy women birthing at term received intranasal fentanyl (n=37), subcutaneous fentanyl (n=37), or intramuscular pethidine (n=35)., Findings: While maternal characteristics and birth outcomes were comparable between groups, women who received either intranasal fentanyl or subcutaneous fentanyl experienced fewer difficulties in establishing breastfeeding by 6 weeks postpartum when compared to intramuscular pethidine (p<0.01)., Key Conclusions: Women who received fentanyl reported that their neonates had less difficulties establishing breastfeeding, compared to those who received pethidine. Therefore, for woman who intend to breastfeed, fentanyl should be the preferred opiate, for the relief of pain in labour., Implications for Practice: When providing education to women in relation to intrapartum pain relief it is important to consider the potential influence on breastfeeding experience. This research provides evidence that fentanyl is a suitable alternative to pethidine for women requesting parenteral analgesia in labour., (Copyright © 2017 Elsevier Ltd. All rights reserved.)