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Continuity of midwifery care has demonstrated some beneficial outcomes for mothers and their babies with no evidence of poorer outcomes. Much of the evidence to support this claim is sourced from research conducted with women described as ‘low risk’. The model of midwifery in New Zealand, which is based on continuity of midwifery carer, has the potential for midwives to continue care even when significant risk has been identified. This care would be provided in collaboration with and support from medical personnel and hospital-based midwives. There is no research that has specifically examined the outcomes for women with complex needs, also called ‘high risk’, who have been provided continuity of midwifery carer. Given the increased incidence of morbidity in the childbearing population it is important to examine this issue in some depth. This small piece of research begins this, by looking at how women with complex needs and who have had continuity of midwifery care have experienced this care. The aim of this research therefore is to provide a comprehensive description of how women with complexities experience continuity of midwifery care across the maternity episode. A qualitative descriptive study was conducted in one part of New Zealand. Three women, all with varying types of complexity were interviewed. The interviews were transcribed, and the transcripts were analysed thematically. There were four themes: the relationship was everything; knowing what was happening was important; power was managed and balanced; and extra care was needed. The three women had the same needs and experiences of continuity as did low risk women described in the literature. However, another aspect, not previously reported, was that the women thought that the midwives spent a lot more time with them than they otherwise would have needed to. They were grateful for this.

In New Zealand women choose their place of birth in partnership with their Lead Maternity Care (case loading) midwife, with most choosing a hospital regardless of their lack of risk factors. The reasons why most women in western countries choose to birth in hospital have been widely investigated. Risk aversity is most commonly implicated. For both women and health professionals this powerful discourse persists despite consistent research findings indicating higher rates of normal birth, and lower rates of maternal morbidity associated with interventions for healthy women who birth in out-of-hospital (primary) maternity units, with no difference in neonatal outcomes. There is however a gap in the literature regarding what is known about how midwives might positively influence the choice to birth in a primary unit. A qualitative descriptive design through an appreciative inquiry lens enabled insight from 12 midwives who have a higher ratio of women within their caseload who choose to birth in a primary unit. Four focus groups were formed with these midwives to explore their perspectives and approaches as they assist women to make their place of birth decisions. From thematically analysed data, five themes emerged, Ways of knowing: woman, art, science and research; Trusting in you, me, and the process of childbirth; Setting boundaries as a ‘primary birth midwife’; and Delaying and diverting, a malleable approach, centered around the theme When it matters what we say: reframing safety and risk. Alongside supporting current research, this study adds to the body of knowledge about birthplace choice by bringing to the fore the notion of paradox in practice, setting boundaries whilst remaining malleable for example. In a contemporary maternity context, these midwives dance between two worlds fundamentally at odds with one another, effectively managing contradiction, complexity and uncertainty to achieve a high primary unit caseload. The experience of what works to promote t

Human infants share common biological and developmental needs in the postnatal period that are optimally met during intimate contact with their mother or primary caregiver. In the case of infants hospitalised in tertiary-level neonatal intensive care units (NICUs), there is a departure from instinctual caregiving and nurturing found in the mother-infant pair, due in part, to a model of care which supports maternal-infant separation. This can lead to suboptimal physiological responses, altered neurobiology and life-long negative health effects. The social construction of neonatal care currently positions it within the paradigm of biomedical science. Where family-centred, developmental care frameworks have been integrated, and Kangaroo Mother Care (KMC) has been embedded into caregiving routines, enhanced patient, whānau/family, staff and organisational outcomes have been found. This study is underpinned by the importance of KMC for the enhancement of infant and whānau/families’ health and developmental outcomes. Despite its classification as an evidence-based practice, and recommendations by the World Health Organisation for its use in all healthcare settings, KMC is inconsistently applied. The highly complex and contextual nature of the environments where medically-dependent babies are cared for is acknowledged. There is a need for health services to explore innovative research approaches, through a social science lens, to assist in the implementation of KMC. This thesis illustrates one such approach. The purpose of this study was to explore and activate improvement of the KMC programme within one NICU in Aotearoa New Zealand using Participatory Action Research (PAR). The research was theoretically informed by Als’ developmental biology and care theories, D’Agata’s Infant Medical Trauma model, and the Foucauldian concept of power/knowledge through a critical feminist lens. A participatory approach was chosen in the hope that transformation of KMC practice would be a

Each year in Nigeria 314,000 mothers lose their babies to stillbirth. This study investigates the implications of these stillbirths for Nigeria’s Yoruba women, especially in relation to their social networks. The study is theoretically framed within the theory of social capital and the research methodology is phenomenography, a qualitative approach that concerns itself with difference in relation to experience. Twenty mothers of stillborn babies were purposefully recruited from Saki, a Yoruba community in South-west Nigeria. Data were collected through semi-structured interviews, participants’ drawings and a focus group discussion. The transcribed data were analysed according to the principles of phenomenography. This yielded four broad categories: (1) relationships change; (2) relationships matter; (3) material support makes a difference; and (4) health professionals neither help nor support. These findings indicated that stillbirth interfered with the social networks of the participants, leading to a decline in their social networks and an emergence of the family as the primary source of support. The participants gained encouragement and empathy through their relationships with others but received minimal material support, even though it was badly needed. The participants expressed distrust in health professionals due to a lack of compassionate care. This study contributes to the understanding of stillbirth bereavement in three different ways. First, culture really matters in how mothers of stillborn babies express their grief, how they are supported and how they would want to be supported. Second, there is still a deficit of kind, compassionate and skilled nursing care for mothers of stillborn babies. Third, support becomes smaller, but more intense for mothers after suffering a stillbirth. This study, therefore, adds to the ongoing global conversations about how better bereavement care can become more realistic for mothers of stillborn babies by extending the th

In developing countries such as Indonesia, women face many health issues, including cancer. Social, cultural and economic factors are known barriers to women accessing health services and achieving a good health. Studies in Indonesia suggest that husbands’ support may influence women’s health behaviour, including women in breast and cervical screening and treatments. However, little is known in Indonesia about husbands’ roles in women’s health, including illness prevention, early detection, and treatment of women’s cancer. The main objectives of this study were to uncover Muslim husbands’ roles and perspectives regarding women’s health and women’s cancer, and to establish whether there were different perspectives of husbands’ roles related to geographical location, age or other social, health or cultural characteristics. This study used an Islamic ontological approach. The Basic Model of Religiosity and Health, the Health Belief Model, and the Help-Seeking Behaviour and Influencing Factors Framework theories informed data collection. A descriptive exploratory methodology was used. Methods included focus groups with 11 groups (n=73) of married Muslim men, and interviews with married Muslim women (n=20) and health professionals (n=10) from rural and urban areas of West Java province, Indonesia. Data were analysed using two techniques: the Comparative Analysis for Focus Group and the Comparative Analysis for Interviews. The findings revealed that Islamic teaching has an extremely significant position for Muslims husbands in guiding them in their family’s roles. Muslim husbands were very involved in women’s health and cancer. These roles were influenced by internal and external factors. Husbands’ significant roles in women’s health include maintaining women’s health and facilitating health treatments. However, they have a limited role in disease prevention, and early detection of women’s cancer. Muslim husbands’ limited health literacy of women’s cancer was a significan

The aim of this study was to explore married Muslimman’s perceptions related to breast and cervical cancer inorder to gather information of about their roles in women’scancer. A descriptive exploratory approach was used involvingfocus group with 11 groups (n=77) of men from rural andurban areas of West Java province, Indonesia. Data wereanalyzed using The Inductive Comparative QualitativeAnalysis Approach in Focus Group (ICQAAF). Men perceivedthat cancer is a fatal disease for women because they regard itas deadly, dangerous, scary, and costly. Participants also citedthat this disease is given from God, and He will help to cure it.The study highlights that men views of women’s cancer arevarious and influenced by experience of cancer in their familyor communities, and beliefs. Men’s perceptions of women’scancer could be influence to their roles in women’s health.

The objective of this mixed method piece of descriptive research is to analyse travel patterns of New Zealand women relating to their selected place of birth, focusing on residents of the Southern District Health Board. It also explores the motivations of a sample of women in this area regarding their birth place choices. Data extracted from Southern District Health Board 2013 electronic records, were analysed using geographic information system software. Spatial modelling was also conducted using this dataset. The second part of the study involved a questionnaire issued to women in Southern District Health Board maternity facilities during a three month period in 2014. In the analysis of 2013 data that women appeared to be by-passing smaller primary maternity units in preference for larger complex care facilities. Spatial modelling examined some possible geographic reasons for this and improved service placement was also modelled based on 2013 demand. Survey results were congruent with other similar research, in that the main reasons for women choosing birth place were a combination of seeking out a safe place whilst remaining as close to home as possible. These priorities caused a tension of distance for rural women. There was no significant statistical variance in the responses between demographic groups. Women are prioritising safety when they choose their birth place. In a large sparsely-populated District Health Board like Southern, this results in some women making long journeys to their chosen birth place as they select complex care facilities over closer primary maternity units or home.

Background: Despite the known benefits of breastfeeding to the mother, baby and society as a whole, young women’s breastfeeding rates are generally poor compared to older mothers. Effective antenatal education has been identified as one way to improve these rates. Whether or not antenatal breastfeeding education for young women can make a significant impact on their breastfeeding success is of paramount concern in this research. An important and modifiable variable, identified in the literature as influencing breastfeeding outcomes, is self-efficacy (confidence in ability to breastfeed). This breastfeeding self-efficacy in young mothers is of great interest due to this group and their infants being vulnerable in terms of breastfeeding initiation and continuation. Aim: This study aimed to identify the effects of antenatal breastfeeding education on the self-efficacy, experience and duration of breastfeeding for young women. It also aimed to replicate aspects of prior research in this area conducted overseas to see if those findings could be generalized to a New Zealand setting. Method: A repeated measure design using an existing validated tool was utilised to quantify breastfeeding self-efficacy, prior to and following, an antenatal breastfeeding education session for young pregnant women aged less than 25 years old. Findings: Breastfeeding antenatal education improved breastfeeding self-efficacy scores in urban young women less than 25 years of age. The Breastfeeding Self-efficacy Scale (short form), was found to be a reliable tool to test this. Whilst initiation rates were high in this group, there was no statistically significant link with breastfeeding self-efficacy and the duration and continuation of breastfeeding. Conclusion: Whilst breastfeeding antenatal education was shown to increase breastfeeding self-efficacy, there are many confounding factors influencing breastfeeding initiation and continuation for young women. The findings have contributed to the kno

The aim of this research was to describe how undergraduate midwifery students’ engagement with learning is impacted when they have teaching delivered by different methods of instruction. It asks the question: does flexible delivery of teaching impact on their ability to engage in their learning? This research describes the impact of different modes of flexible delivery of teaching within a new curriculum on students in a pre-registration midwifery undergraduate programme at Waikato Institute of Technology (Wintec), New Zealand. This new curriculum commenced in 2010 as a response to legislative and industry driven changes to midwifery education in New Zealand. The research used an on-line survey to ask students enrolled in years one and two of the programme and those who had exited the programme during the same timeframe, A range of questions about their learning experiences. Surveys were sent to 104 enrolled students and 15 students that had exited the BMid programme. Fifty two (50%) responses were received from the enrolled students and three (20%) from those that had exited the programme. There were three key findings of this research. Firstly the participants identified differences with their sense of belonging amongst their peers, tutors and the administration team outside of their regional learning hubs. The second key and unsurprising finding was that respondents across the board preferred face-to-face sessions to video conferencing sessions and thirdly that the demographic profile of the respondents from the regional learning hubs was different to those attending from the Hamilton city hub. The implications of these key findings are; · For tertiary institutions to acknowledge and consider the links between high quality learning, student engagement and outcomes. · To support the need for continuing training and education for both faculty and students with regards to flexible delivery of teaching and to provide professional development and relevant technology t

This research describes the model of midwifery care embedded in Newtown Union Health Service (NUHS). This model of care is different from the way most midwifery services in New Zealand are organised. The main New Zealand midwifery services are provided by self-employed midwives and hospital midwives. NUHS was set up to provide accessible health services to a low income population. Pivotal to the service is the employment of a multidisciplinary team which aims to meet most of the health needs of its registered population. As the NUHS midwifery service was set within the larger organisation the case study research method was chosen as it is a method which stresses the importance of understanding the context of a case. It permits the use of several sets of data to capture the complexity of a case. Data collection included interviews with five midwives and seven multidisciplinary team members including managers working at NUHS. An unsuccessful attempt was made to gain access to and interview pregnant women who had used this service. Other data came from several documents about the Newtown community and the service. Data analysis revealed that the NUHS model of midwifery care was made up of five interrelated and interacting components: the community, NUHS, the midwives as integral to the multidisciplinary team, the midwives and the women in the care of the midwives. A discussion of the model includes what was extrapolated as three distinctive features of the model: their philosophy, the union influence and the midwives in the multi disciplinary team. The NUHS model of midwifery care is then related to other national and international models where its distinctiveness is supported.

Over the past three years there has been an increased focus on reducing global maternal mortality in developing countries. While substantial progress has been made, improvement remains slow in some areas. Making formal maternal healthcare services more acceptable, affordable and accessible to rural communities where the majority of maternal deaths occur, remains a considerable challenge. This study looks at the model of professional midwifery training employed at La Escuela de Partería Profesional de CASA [the CASA School of Professional Midwifery] in San Miguel de Allende, Mexico, whose aim is to train professional midwives who will provide culturally acceptable services in rural communities. It examines how the school's model reflects the development concept of community participation. This study adopted a single case study methodology to examine community participation at the CASA School of Professional Midwifery. Data collection techniques included the use of Semi-structured interviews, Focus Groups, Participant Observation and Document analysis. The study found that the CASA School included elements of participation within its model and highlights the different ways in which outsiders and insiders may arrive at implementing community participation-type processes in development initiatives. The study also finds that because of differences between the biomedical and development paradigms, the reality for many communities is that they are only permitted to participate in the maternal healthcare paradigms and models sanctioned by the state. The conclusion was that the CASA model of professional midwifery offers a new way to think about the relationship between maternal health professionals and the community, and of integrating communities back into the maternal health discourse.

Intermittent Auscultation (IA) of the fetal heart (FH) is a screening tool for the assessment of fetal well-being during labour; the detection of changes in the FH rate and rhythm may signal fetal compromise. While the evidence reveals that IA is as effective as continuous cardiotocography (CTG) for FH monitoring for low-risk women, current practitioners favour the use of continuous CTG despite the risk of significantly increased maternal and fetal morbidity. Translating the knowledge of the effectiveness of IA into practice became the primary aim of this study. While auscultation and palpation are essential midwifery skills, the teaching of IA does not go beyond simply outlining the protocol for frequency, duration, and timing and less is understood about the underlying physiology associated with what is heard and the reassurance of fetal wellbeing that this provides. A knowledge translation intervention, in the form of an evidence-based informed decision-making framework for Intelligent Structured Intermittent Auscultation (ISIA) and a comprehensive educational intervention were developed to enhance midwives‘ knowledge and awareness of IA and to influence decision-making and practice for FH monitoring for low-risk women. A mixed methods non-experimental pre- and post - intervention study design was used to evaluate the knowledge intervention. Pre measures included a retrospective review of 511 medical records to assess existing FH monitoring practices, and focus groups with 14 midwives explored barriers and facilitators to the use of IA. The intervention was then delivered to a mix of 33 midwives and doctors three months later, followed by a second review of 422 medical records and focus groups with seven midwives to determine any changes in practice and to evaluate outcomes. The findings revealed a statistically significant increase in the use of ISIA with improved documentation, and a relative decrease of 14% in the use an admission CTG for low risk women. The I

Identifying small for gestational age (SGA) and large for gestational age (LGA) babies is important, because these babies may be at increased risk of hypoglycaemia at birth. It is proposed that customised birthweight centiles (CBWC) can more accurately identify these babies by taking into account several physiological variables of the pregnancy affecting birthweight. These variables are: maternal height and booking weight, ethnicity, parity, the baby's gender and gestation. CBWC for a New Zealand (NZ) population were developed by McCowan, Stewart, Francis and Gardosi (2004), and can be downloaded for free from www.gestation.net. Using CBWC is not in common practice in NZ, even though its use was discussed in a 2007 Health and Disability Commissioner report in relation to neonatal hypoglycaemia. The setting for the study was a NZ District Health Board (DHB) that calculates a CBWC for each birth. The research question asked how the evidence behind CBWC was put into practice and what outcomes resulted from translating this knowledge into action. This was a mixed methods evaluation which included interviews, focus groups, an audit and document analysis. The knowledge-to-action (KTA) framework (Straus, Tetroe, & Graham, 2009) was used as a theoretical template to describe the implementation process that occurred. The results revealed that maternity care providers were initially challenged by the evidence. But over time, guideline compliance improved as practitioners experienced the benefit of using CBWC in practice. All agreed that the CBWC calculator was user-friendly. However, the audit demonstrated it was easy to make a mistake or manipulate results when using the calculator. CBWC can help identify babies at risk of hypoglycaemia who otherwise would have been missed. But it is unknown what difference it had made in improving neonatal morbidity and mortality, due to insufficient data. But anecdotally, stakeholders felt it had made a difference. The findings demonstrate

Within childbirth there is a common and widely known explanation of labour and birth which describes and defines the birth process as that of stages and phases. The boundaries between the stages and phases have been determined by cervical dilatation with time parameters set to measure progress. The measurement of cervical dilatation is determined by a health professional and has resulted in an apparent inability of women to determine themselves whether they are in labour and their closeness to the impending birth. The aims of this thesis were threefold; the first was to critically examine the knowledge base of labour progress, so that the influences on knowledge development were fully understood. Through exploring the historical and theoretical development I found that the current knowledge has come from a male understanding of female anatomy and observational data constructed within a discourse of male, medical, scientific superiority. The second aim of the thesis was to explore the perspectives of women who had experienced a spontaneous labour and birth in order to determine whether the discourse of labour as stages and phases resonated with them. This leads to the third aim of providing a description of the women’s voices and perspectives based on their experiential knowledge of spontaneous labour and birth. A critical feminist ontology and feminist standpoint methodology guided the research which used in-depth one-to-one interviews with 18 women who had experienced a spontaneous labour and birth. Early thematic analysis was developed further through feedback from the participants supporting a coconstruction of knowledge. Analysis revealed that women considered the stages and phases of labour to be an abstract concept which did not resonate with their experiences of labour and birth. An important aspect of labour was having support during the process, in terms of both emotional and physical support from midwives, partners, family and friends present during the la

This descriptive, correlational study was designed to describe levels of consumer satisfaction with emergency department (ED) nursing and to identify the key determinants of satisfaction with ED nursing in a regional New Zealand hospital. The relationship between satisfaction with ED nursing and with overall satisfaction with the ED visit was also explored. Satisfaction is an important indicator of the quality of healthcare and an understanding of satisfaction and its determinants has the potential to improve healthcare services and consumer health outcomes. The study employed a survey design using the Consumer Emergency Care Satisfaction Scale (CECSS) which is an internationally recognised tool that has demonstrable reliability and validity. It consists of 19 items divided between two subscales - Caring and Teaching. Respondents indicate on a five point Likert scale the extent to which they agree or disagree with each item. In addition to the 19 items in the scale, respondents were also asked to provide some consumer characteristic data and to answer two open-ended questions. The survey was posted to a convenience sample of 410 ED attendees within 24-48 hours of their visit to the emergency department. The final sample comprised 100 completed or partially completed surveys. The majority (n = 65, 88%) were either satisfied or very satisfied with ED nursing. There were no statistically significant relationships between any consumer characteristics and satisfaction; however the following visit characteristics were demonstrated to affect levels of satisfaction - triage category, self-rated acuity, the times consumers arrived at and were discharged from the ED, being able to differentiate between health professionals, being kept informed about the visit and any delays, length of stay (LOS), and number of previous visits to the emergency department. There was a strong positive correlation (r = 0.571, p = 0.000) between consumer satisfaction with ED nursing and with overa

Making decisions about the reasons for, and the timing of transfer to specialist care from rural maternity care were examined in this study. This is a time when women and midwives 'travel hopefully' through labour and birth aware of their rural context. A Mixed Methods Research (MMR) approach was used to gather data from a national survey of rural maternity units together with individual and small group interviews of women and of midwives. A modified Concurrent Mixed Model Design was used to structure the research process with each data strand collated and discussed consistent with its paradigmatic roots. The findings were then drawn together in a metainference. A 17% rate of transfer during labour and up to 6 hours postpartum was found for the two year period examined. Slow progress in labour was the most common reason for transfer. Interviews with rural women and midwives revealed a similar range of decision making styles. The strategy of 'thinking ahead' emerged as a common theme which allowed for the distance and time involved in the transfer and in anticipation of critique from the secondary care system and local community.This thesis makes a significant contribution to the national and international understanding of the experience of maternity transfer in rural areas and finds that within a regionalised perinatal system, midwives make cautious and timely decisions about transfer in labour and birth. Further, that a rural birthing service contributes to the health and well being of the community and ought to be appropriately resourced to provide the optimal environment for safe decisions about transfer.

A woman's first birth experience can be a powerfully transformative event in her life, or can be so traumatic it affects her sense of 'self' for years. It can influence her maternity future, her physical and emotional health, and her ability to mother her baby. It matters greatly how her first birth unfolds. Women in Aotearoa/New Zealand enjoy a range of options for provision of maternity care, including, for most, their choice of birth setting. Midwives who practice in a range of settings perceive that birth outcomes for first-time mothers appear to be 'better' at home. An exploration of this perception seems warranted in light of the mainstream view that hospital is the optimal birth setting. The research question was: "Do midwives offer the same intrapartum care at home and in hospital, and if differences exist, how might they be made manifest in the labour and birth events of first-time mothers?" This mixed-methods study compared labour and birth events for two groups of first-time mothers who were cared for by the same midwives in a continuity of care context. One group of mothers planned to give birth at home and the other group planned to give birth in a hospital where anaesthetic and surgical services were available. Labour and birth event data were collected by a survey which was generated following a focus group discussion with a small group of midwives. This discussion centred around whether these midwives believed their practice differed in each setting, and what influenced care provision in each place. Content analysis of the focus group data saw the emergence of four themes relating to differences in practice: midwives' use of space, their use of time, the 'being' and 'doing' of midwifery and aspects relating to safety. Survey data were analysed using SPSS. Despite being cared for by the same midwives, women in the hospital-birth group were more likely to use pharmacological methods of pain management, experienced more interventions (ARM, vaginal exami

In New Zealand there are concerns about the high numbers of preventable admissions of young children with acute illnesses. These admissions are concentrated in the under five age group, with higher rates of admissions for tamariki Maori and Pacific children. This study sought to address these concerns by focusing on what happened once these children were discharged. Its aims were to find out what the expressed needs of parents were, as they cared for their child, once home. Whilst there has been a small amount of international research undertaken in this area, there is little known about expressed parent need in the New Zealand context. This exploratory descriptive study involved parents of under five year old children, who had been admitted to a hospital, with one of five acute illnesses. Eighteen parents were surveyed over the telephone. This study found the parents expressed a need for reassurance and advice once home, and that they worried about their child getting sick again. It highlighted gaps in discharge planning and support. None of the parents had received a written discharge plan for their child. Only five parents had received either a contact number for advice or a referral back to their primary care provider. This study found that whilst some parents considered their discharge needs had been met, others considered that they had not. Four local discharge practice opportunities to support these families were recommended, these included, providing parents and caregivers with an individualised written discharge plan, giving a contact number for advice after discharge, offering a follow-up phone call in the first 48 hours, and ensuring that all children have a referral back to their primary health care provider. Areas for further research were highlighted, including the need for a larger study to explore and compare the needs of rural and urban parents, and Maori and Pacific parents.

In recent years, as a result of globalisation and increased immigration from countries known to engage in Female Genital Mutilation (FGM), exposure to the results of the centuries old tradition/cultural practice of FGM Type III is becoming part of the New Zealand midwifery experience. While a wealth of information exists around the FGM procedure itself, little research has been specifically documented about the midwives' experiences of caring for women in childbirth who have undergone this procedure. This study captures the experience of a small group of midwives, caring for women who have undergone FGM Type III, during the childbirth experience. It focuses on the feelings and experiences of the midwives during the process of labour and birth. An interpretive approach was adopted, using in-depth open-ended interviews, in order to explore, to gain insight and to understand the midwife's experience. The study recognises there are many different possible interpretations with midwives 'telling their story', and identifies issues that they encountered in providing care for these women. Four themes were identified in the midwife's experience: 'feeling unprepared', 'negotiating the cultural gap', 'the traumatic reality of deinfibulation' and 'tensions and paradoxes'. These reflect the journey of the midwife through their experiences and the challenges they faced. This research proposes that midwives require further support in their theoretical and practical knowledge in caring for women who have undergone FGM Type III. It also highlights the lack of structured support and information that surrounds their care.