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Background: Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders., Methods: Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM., Results: Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences., Conclusion: This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations., (© 2024 The Authors. Birth published by Wiley Periodicals LLC.)

Background: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration., Methods: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality., Results: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country., Conclusions: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes., (© 2024. The Author(s).)

Background: The Vietnam midwifery report acknowledges that while health services are available in Vietnam, there is growing need to increase levels of respectful maternal care provided to women in labour., Objective: In conjunction with newborns Vietnam charity, our objective was to assess the perceived continuous professional development needs of midwives working in Vietnam to inform development of an intranatal respectful maternal care education resource., Method: A qualitative exploratory descriptive method was used to conduct a training needs analysis, which identified perceived education requirements of midwives in Vietnam in relation to providing respectful maternal care., Participants: A convenience sample of midwives (n = 49) participated in the study., Data-Collection: Eight on-line focus groups were carried out in four hospitals (maternity units) across Vietnam using WebEx, with the interview schedule informed by the World Health Organization guide for delivering intrapartum care for a positive birth experience., Data-Analysis: Data were transcribed into English and analysed using the 6-steps of thematic analysis outlined by Braun and Clark., Findings: Three themes and 9 sub-themes were developed from the data. The first theme addressed aspects that contribute towards creating a positive birth experience; the second theme observed barriers to changing practice; and the third theme noted that there are a variety of preferred teaching methods., Conclusions: In response to the training needs analysis, a respectful maternal care education resource has been designed to transform selected areas of intranatal care in Vietnam. Integrating the respectful maternal care educational resource into midwives' continuous professional development in Vietnam is intended to increase women's rights to have safe childbirth, which accommodates choice and control, and promotes a positive birth experience., Recommendations for Practice: Post-completion and evaluation, we hope that the intranatal respectful maternal care educational resource will be rolled out to all practising midwives in Vietnam., Competing Interests: Declarations of interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The role of the midwife is emotionally demanding with many midwives experiencing high levels of stress and burnout, and a great number considering leaving the profession. This has serious implications for the delivery of high-quality, safe maternity care. One of the major factors leading to job dissatisfaction is the conflict between midwives' aspiration of truly 'being' with the woman and the institutional expectations of the role which focuses on the 'doing' aspects of the job. 'Being' present to a woman's psychological needs, whilst meeting the institutional demands, requires high levels of emotional intelligence (EI) in the midwife. Therefore, enhancing midwives' EI could be beneficial., Ei Education Programme: An EI programme was made available to midwives with the intention to promote their emotional intelligence and enable them to utilise relaxation techniques for those in their care., Aim: To explore midwives' perspectives on the influence of the EI education programme on their emotional wellbeing and experiences of practice., Method: The study took a descriptive qualitative approach. Thirteen midwives participated in focus group interviews. The data were analysed using thematic analysis., Findings: The overarching theme of 'The Ripple Effect' included three themes of 'Me and my relationships', 'A different approach to practice' and 'Confidence and empowerment'. The programme was seen to create a positive ripple effect, influencing midwives personally, their approach to practice, and feelings of confidence in their role., Conclusion: EI education can reduce emotional stress in midwives, enhance their empathy and feelings of confidence, thus, improving the quality of care they provide., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Midwives encounter various difficulties while aiming to achieve excellence in providing maternity care to women with mobility disabilities. The study aimed to explore and describe midwives' experiences of caring for women with mobility disabilities during pregnancy, labour and puerperium in Eswatini., Methods: A qualitative, exploratory, descriptive, contextual research design with a phenomenological approach was followed. Twelve midwives working in maternal health facilities in the Hhohho and Manzini regions in Eswatini were interviewed. Purposive sampling was used to select midwives to participate in the research. In-depth phenomenological interviews were conducted, and Giorgi's descriptive phenomenological method was used for data analysis., Results: Three themes emerged from the data analysis: midwives experienced physical and emotional strain in providing maternity care to women with mobility disabilities, they experienced frustration due to the lack of equipment to meet the needs of women with mobility disabilities, and they faced challenges in providing support and holistic care to women with mobility disabilities during pregnancy, labour and puerperium., Conclusions: Midwives experienced challenges caring for women with mobility disabilities during pregnancy, labour and the puerperium in Eswatini. There is a need to develop and empower midwives with the knowledge and skill to implement guidelines and enact protocols. Moreover, equipment and infrastructure are required to facilitate support and holistic maternity care for women with mobility disabilities., (© 2024. The Author(s).)

Background: The concept of professional midwifery autonomy holds great significance in midwifery education. Notably, clinical placements play a crucial role in introducing students to its concept. However, the understanding and experiences of students regarding midwifery autonomy are relatively unknown., Objectives: This study aimed to examine the experiences and understanding of midwifery autonomy among final-year midwifery students., Methods: A qualitative exploratory study using three focus group interviews with final-year midwifery students from each of the three Belgian regions; Flanders, Walloon and the Brussels Capital Region. Focus groups were recorded, transcribed verbatim and analysed using a thematic analysis., Results: Upon data analysis, five key themes emerged; 1) working independently, 2) positive learning environment, 3) professional context, 4) actions and decisions of others and 5) beneficial for women. Students emphasized the importance of promoting professional midwifery autonomy through the ability to make their own professional decisions and take initiatives. They highlighted the need for a safe and supportive learning environment that encourages independent practice, nurtures self-governance and facilitates personal growth. Additionally, collaborative relationships with other maternity care professionals and increased awareness among women and the broader healthcare community were identified as essential factors in embracing and promoting professional midwifery autonomy., Conclusions: Our study provides valuable insights into the significance of midwifery autonomy among final-year midwifery students. To empower midwifery students to truly understand and experience professional midwifery autonomy, educators and preceptors should adopt strategies that enhance comprehension, foster independent yet collaborative practice, establish supportive learning environments, and equip students to navigate challenges effectively, ultimately improving maternal and new-born health., Competing Interests: Declaration of competing interest None. This research did not receive any specific grant from funding agencies in the public, cmmercial, or not-for-profit sectors., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To explore the experience of primi- and multiparous women with planned singleton upright breech births., Method: We conducted face-to-face, in-depth interviews with five primiparous and five multiparous women who underwent a physiological breech birth at one hospital in Norway and analyzed the data using Giorgi's descriptive phenomenological method., Results: The phenomenon of women's experiences with physiological breech birth yielded four main constituents: "Mental preparedness and control", "The importance of shared decision-making and sufficient information", "Trust and the many 'faces' of birthing staff", and "'I actually did it!': Coping and control in the upright breech position". The significance of readiness, the influence of previous experiences and information, and the establishment of trust in midwives and gynecologists emerge as dominant themes. The sense of co-determination, control, and mastery is also highlighted., Conclusions: Our findings underscore the pivotal role of personal attributes in fostering mental preparedness when confronted with unforeseen aspects of childbirth. Notably, women's experiences with upright breech birth vary; while some perceive it as an ideal birth, others find it more challenging. Factors such as unpreparedness, lack of information, diminished co-determination, and loss of control negatively impact birth experiences. This study's findings underscore the significance of tailoring maternity care to individual needs and improving information sharing. These measures are paramount for optimizing women's experience during upright breech births., 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 B.V. All rights reserved.)

Objectives: We assessed the knowledge and attitude of registered midwives towards collaborating with traditional birth attendants for maternal and neonatal healthcare services in rural communities., Design: A descriptive cross-sectional survey was followed in this study., Participants: Registered midwives in selected clinics in the City of Tshwane Municipality. Participants were recruited by stratified random sampling. Data was collected at the Thirty-four primary healthcare facilities in Gauteng province, South Africa., Measurement and Results: A self-assessment questionnaire was administered to 304 registered midwives. Two-hundred and sixty respondents returned the questionnaire representing a response rate of 86.6 % which was statistically significant. The majority of Midwives in South Africa displayed a low level of knowledge (mean = 41.8, SD=1.7) on the role and practices of traditional birth attendants). Only 30.8 % (n = 80) of midwives knew of the roles of traditional birth attendants for maternal and neonatal healthcare (MNH) services. With respect to knowledge, there was significant associated with the Professional category (p < 0.015). In terms of attitude, registered midwives displayed negative attitudes towards collaborating with traditional birth attendants (mean = 46.8, SD=2.1). Approximately half (54.2 %, n = 140) of midwives were amenable towards collaborating in the provision of antenatal care, and 70.4 % (n = 183) of midwives agreed to collaborate with traditional birth attendants for extended roles such as accompanying women to health facilities. Association of demographic data and level of attitude showed there was significant relationship (p < 0.05) between registered midwives' level of education and their attitude towards collaboration., Key Conclusions: Midwives demonstrated positive attitude towards collaborating with traditional birth attendants at the antenatal care level only. Midwives were not amenable to collaboration at the level of intrapartum and postpartum care., Implications for Practice: Based on our results, collaboration should be at antenatal care level to allow for early detection, treatment, and prevention of antenatal complications thus reducing maternal mortality and morbidity., 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.)

Problem: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities., Background: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma., Aim: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives., Methods: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables., Findings: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001)., Discussion: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern., Conclusion: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: We explored midwives' experiences and challenges in providing maternity care during the period of the first surge of the COVID-19 pandemic in Dodoma., Design: Phenomenological study design was used to explore midwives' experiences and challenges in providing maternity care during the COVID-19 pandemic in Tanzania., Methods: We conducted interviews with a total of 23 midwives, using semi-structured interviews and an audio recorder. Five focus group discussions (FGDs) were conducted. To analyse the data, we used interpretive phenomenological thematic data analysis with NVivo software. To analyse templates, we followed a step-by-step process, starting with familiarizing ourselves with the data, followed by preliminary coding, organizing themes, developing an initial coding template, using the initial template, refining the template and finally applying it to the entire dataset., Results: It was found that three themes and eight subthemes merged in the current study. The main themes were ① mental health distress, ② work environment challenges and ③ isolation of midwives by different groups., Public Contribution: Reducing risk and protecting midwives from infectious diseases will improve the workforce, reduce the number of hospital stays, reduce the cost of hospital services, improve birth outcomes and indirectly improve family, community and national economies., Conclusion: Due to the system's failure to provide psychological support, protective environment and isolation rooms for confirmed or suspected cases put midwives at a higher risk of contracting the virus and had to work in a stressful environment. In addition to having the right tools, midwives must also receive emotional and psychological support in order to be at their best. The system must ensure that midwives are ready for uncertain times, such as pandemic infectious disease outbreaks, by providing protective work place environment such as personal protective equipment, psychological support and isolation room for confirmed COVID-19 cases., (© 2024 The Authors. Nursing Open published by John Wiley & Sons Ltd.)

Introduction: Respectful Maternity Care (RMC) is "a universal human right for every childbearing woman". In Rwanda, few studies conducted on RMC assessed how women perceive care provided during childbirth, yet little is known about providers' perspectives. We investigated the perceptions and attitudes of midwives towards the provision of RMC to complement women's viewpoints., Methods: this qualitative study used individual in-depth interviews in Kinyarwanda language. A purposive sampling method was used to reach out to twenty-eight midwives from three district hospitals in Kigali City. Transcribed interviews were translated into English and thematic content analysis was performed using Atlas Ti, version 7. The University of Rwanda College of Medicine and Health Sciences Institutional Review Board (Ref: 363/CHMS/IRB/2019) ethically approved this study before data collection., Results: the majority of participants revealed that they have knowledge on RMC and perceive that they provide maternal health care based on women´s rights. Positive attitudes towards providing RMC were reported by midwives, however, a considerable number of participants reported the existence of abusive practices. The majority of midwives reported facing many challenges affecting their ability to provide respectful maternal care., Conclusion: midwives understand the seven rights of women and have a positive attitude towards providing RMC. However, abusive practices still exist while providing RMC with considerable challenges, including overload and lack of labour monitoring materials. The adjustment of the ratio of midwives to clients and the availability of essential materials in labour monitoring is recommended to improve the quality of healthcare received by women during childbirth., Competing Interests: The authors declare no competing interests., (Copyright: Valentine Uwamahoro et al.)

Objective: Swedish healthcare policies promote gender equality, shared parenting and cultural diversity. In response to the risk of adverse outcomes for migrant women, cultural doulas were introduced as support for migrant women during pregnancy and/or labour. The aim is to investigate potential tensions in the cultural doula concept in relation to policies of gender equality and diversity., Design: An interview study was designed to analyse perceptions of the cultural doula concept among healthcare providers in Swedish sexual and reproductive healthcare. Through the framework of Bacchi's approach 'What Is the Problem Represented to Be?' and Hochschild's concept of 'global care chains', we analyzed whether the introduction of the cultural doula concept is in line with the policies of gender equality and culturally sensitive care by exploring paradoxes, unintended consequences and what was not reflected upon., Setting and Participants: Semi-structured interviews (n = 18) with midwives and obstetricians at hospitals in two Swedish counties during 2022., Measurements and Findings: The interviews were analyzed through thematic analysis. Cultural doulas were perceived as multi-tasking resources for facilitating integration and providing healthcare information and psychosocial support. Respondents did not identify doula support as a cultural practice in migrants' origin countries. Despite awareness of cultural differences in gender norms, many respondents stated that doula support included male partners., Key Conclusions: The cultural doula concept includes paradoxes in relation to gender equality and diversity. Rather than empowering migrant women, the cultural doula concept is related to gendered patterns of low-educated, underpaid care work. Labour support interventions including migrant women's social network and intensified partner involvement would be more in line with Swedish policies of gender equality, shared parenting and cultural sensitivity when needed. However, doulas may be an imperfect solution for women lacking partners or social networks, for example, newly arrived migrant women, if no support is to be found within the perinatal care system., Implications for Practice: Midwives and obstetricians need reflexivity about what the problem is represented to be when it comes to gender equality and cultural sensitivity in their collaboration with cultural doulas, boundaries between roles, how they handle confidentiality, and why cultural doulas are needed in relation to migrant women's integration., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: To explore the perspectives and experiences of community-based doulas and maternity care providers working with each other in Australia; and to identify the facilitators and barriers to working relationships when supporting migrant women during labour and birth., Design and Methods: A qualitative interpretive phenomenological study using in-depth semi-structured interviews. An inductive thematic approach and Capability, Opportunity, and Motivation (COM-B) framework were used in data analysis., Setting and Participants: 10 doulas from Birth for Humankind (a community-based doula service), and 13 maternity care providers from a tertiary maternity hospital in Melbourne, Australia were included., Findings: We identified how collaborative working relationships between community-based doulas and maternity care providers may be enhanced by adopting facilitators across all three COM-B domains and by removing identified barriers. Factors facilitating collaborative working relationships included: knowledge and value of doula roles, establishment of rapport and trust between doulas and providers; doulas enhancing respectful care, communication and relationships between migrant women and providers; and community-based doulas differentiated from private practising doulas. Barriers included: limited understanding of doula roles and service; limiting behaviours impacting collaborative relationships; and limited opportunities for doulas and providers to establish rapport., Key Conclusions and Implications for Practice: Findings are relevant to other models of doula care including private practice doulas and hospital-based doula services. Positive, collaborative doula-provider working relationships are integral for ensuring that the benefits of doula care continue to reach underserved populations such as migrant women and improve their maternity care experiences and outcomes within hospitals settings., Competing Interests: Declaration of Competing Interest The authors declare the following may be considered as potential competing interests: Red Dearnley is the Chief Executive Officer of Birth for Humankind (2018 to present). Kerryn O'Rourke was on the Board for Birth for Humankind and had resigned from this position in 2017, before engaging in her doctoral evaluation research., (Copyright © 2023. Published by Elsevier Ltd.)

Aim: To synthesise findings from published studies, which reported on women's experiences of planning a home birth in consultation with maternity care providers., Design: Systematic Review DATA SOURCES: We searched seven bibliographic databases, (Ovid Medline, Embase, PsycInfo, CINAHL plus, Scopus, ProQuest and Cochrane (Central and Library), from January 2015 to 29 th April 2022., Review Methods: Primary studies were included if they investigated women's experiences of planning a home birth with maternity care providers, in upper-middle and high-income countries and written in English language. Studies were analysed using thematic synthesis. GRADE-CERQual was used to assess the quality, coherence, adequacy and relevance of data. The protocol is registered on PROSPERO registration ID: CRD 42018095042 (updated 28th September 2020) and published., Results: 1274 articles were retrieved, and 410 duplicates removed. Following screening and quality appraisal, 20 eligible studies (19 qualitative and 1 survey) involving 2,145 women were included., Key Conclusions: Women's prior traumatic experience of hospital birth and a preference for physiological birth motivated their assertive decision to have a planned home birth despite criticisms and stigmatisation from their social circle and some maternity care providers. Midwives' competence and support enhanced women's confidence and positive experiences of planning a home birth., Implications for Practice: This review highlights the stigma that some women feel and the importance of support from health professionals, particularly midwives when planning a home birth. We recommend accessible evidence-based information for women and their families to support women's decision-making for planned home birth. The findings from this review can be used to inform woman-centred planned home birth services, particularly in the UK, (although evidence is drawn from papers in eight other countries, so findings are relevant elsewhere), which will impact positively on the experiences of women who are planning home birth., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Financial support was provided by The Southern Health and Social Care Trust HSC Research and Development Fund and matching funding from the Public Health Agency, Northern Ireland, Opportunity Led Research Fund. Patricia Gillen reports a relationship with Southern Health and Social Care Trust that includes: employment., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Problem: Australian First Nations women are more likely to commence care later in pregnancy and underutilise maternal health services than non-First Nations women., Background: Disrespectful maternity care is a major barrier to care-seeking in pregnancy, often resulting in later commencement and underutilisation of care., Aim: We aimed to identify barriers and enablers to pregnancy-related care-seeking for Australian First Nations women living in the Darwin region through yarning about their experiences of pregnancy care., Methods: Ten Australian First Nations women shared stories about their pregnancy care journeys. Yarns took place at a time and location determined by the women, with recruitment continuing until saturation was reached., Findings: Emerging themes included a desire for continuity of carer, particularly with midwives; access to trustworthy information, enabling informed decision-making; and a need to have family involved in all aspects of care. No specific barriers were identified within this cohort DISCUSSION: Universal access to continuity of carer models would provide women with the relational care they are asking for as well as address other identified needs, such as a desire for information relevant to their pregnancy; and space for partners/family members to be involved. The themes that emerged provide a picture of what a positive, respectful pregnancy care experience could be for First Nations women within the Darwin Region, thus enabling care-seeking in pregnancy., Conclusion: Although the public sector and Aboriginal Controlled Community Health Organisations currently provide continuity of carer models, robust systems ensuring these models are made available to all women are lacking., Competing Interests: Declaration of Competing Interest None to declare., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: All women have the right to the highest attainable standards of health, including the right to respectful maternity care (RMC). A qualitative body of knowledge describing midwives' and women's experiences of the value and importance of RMC exists. However, no qualitative synthesis exists about midwives' and women's views of respectful care., Aim: This review aims to present a qualitative synthesis of global perceptions and experiences of midwives and women regarding RMC., Methods: A systematic search was conducted in October 2021 and updated in March 2023 on Science Direct, EBSCO host, PubMed, Nexus and ProQuest databases. The synthesis included qualitative studies published between 2010 and 2023. Qualified midwives and pregnant and postnatal women were the samples of the review. The studies' screening and selection for inclusion in the review are presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart, and the quality of the included studies was appraised using the Critical Appraisal Screening Programme (CASP) tool. Thematic analysis was conducted., Findings: Fifteen studies met the review inclusion criteria involving 266 women and 147 midwives. Five themes were identified from the data: commitment to women's rights; excellence in midwifery knowledge and skills; a facilitative built environment; optimising the interpersonal dimension; and the development of women's resourcefulness and resilience., Conclusion: Maternity care is collaborative, and midwives and women are partners in the process. Midwives play a significant role in promoting women's rights, fostering interpersonal working and client relationships, and addressing women's rights and needs., Competing Interests: Conflict of interest The authors declare no potential conflicts of interest in respect to the research, authorship and/or publication of this article., (Copyright © 2023 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objective: To explore the experiences of midwives in Indonesia on the provision of maternal health services during the COVID-19 pandemic., Design and Methods: A qualitative descriptive study using focus group discussions was undertaken. A conventional content analysis was used to analyze the data. Coding categories were generated from the transcripts., Setting and Participants: Twenty-two midwives from five community health centers of three regions in the Province of Jambi, Indonesia were included., Findings: The interviewees shared similar barriers and facilitators in delivering the services, including the unavailability of adequate protective equipment, the limitation of the number of services, and dealing with the new public health measures related to the COVID-19. Overall, midwives demonstrated a continued commitment to provide maternal health services during the pandemic., Key Conclusions and Implications for Practice: Significant changes in service delivery have been made to comply with pandemic related restrictions. Despite the unprecedentedly difficult working environment, the midwives continue to provide adequate services to the community by implementing a strict health protocol. Findings from this study contribute to a better understanding of how the quality of the services changed, as well as how new challenges can be addressed and positive changes can be reinforced., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Problem: Peer support is understudied as a factor that can impact midwifery student retention., Background: Retention of midwifery students is essential for creating a sustainable maternity care workforce. Research shows that peer support positively influences students' experiences, but it needs more focus on the role peers play in student retention., Aim: We aimed to examine how peer support can facilitate midwifery students' retention by exploring the role peers play in students' experiences and identifying the types of support students offer each other., Methods: We conducted 31 semi-structured interviews with students attending Midwifery Education Programmes across Canada. Data were analysed inductively, following the constructivist grounded theory method., Findings: While motivated and engaged peers improved students' learning experiences and desire to remain in their program, peers who created an overly competitive academic environment hindered learning. Students also noted that a lack of diversity, particularly of Black and Indigenous peers, limited their ability to learn about culturally safe care. Most students felt a sense of community and relied on one another for emotional, academic, and instrumental support., Discussion: Peer support has mostly positive effects on student learning and should be formalized by midwifery educators to improve retention. Reducing pressure to succeed, targeting recruitment of students who are Black, Indigenous, and People of Colour, and establishing formal mentorship programmes could enhance the role peers play in student retention., Conclusion: While retention of students is a complex issue, positive interactions with peers can create a stimulating learning environment and increase students' desire to stay in their programme., Competing Interests: Conflict of interest All authors would like to confirm that they have no financial or other interest and no conflict of interest of any kind relevant to the publication of this study., (Copyright © 2023 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Lack of access to birth facilities and maternity care providers has contributed to rising US maternal mortality and morbidity rates, especially among women in rural areas. Evidence supports the increased use of midwives as a potential solution for access-to-care issues. This observational survey was conducted to identify the practice environment for Certified Nurse-Midwives® in Colorado for the purpose of informing future workforce expansion. Study results indicate that midwives provide services aligned with the midwifery model of care and have mostly autonomous practice in hospitals where midwifery practices are already established. However, there is limited use of midwives, as fewer than half of Colorado's 69 birthing hospitals have midwifery practices, and financial constraint created by low Medicaid reimbursement could be a limiting factor in establishing new midwifery practices. Policy recommendations based on survey results include (a) support for midwifery education and workforce development, (b) removal of hospital-level restrictions for privileges of midwives, and (c) consideration for public payment models that promote expansion of midwifery practices.

Globally 800 women die every day from preventable causes related to pregnancy and childbirth. One of the major reasons for high maternal mortality ratios in many developing countries is the low proportion of births attended by Skilled Birth Attendants (SBA). To address the high number of maternal deaths, in 2008 the Government of Pakistan introduced the Community Midwives Program. Under the program, women from across the country were trained and deployed as Community Midwives. In this study, I use six rounds of Pakistan Social and Living Measurement Survey to estimate the impact of this program on maternal healthcare utilization. I find that women residing in districts with higher Community Midwives per capita were 9 percentage points more likely to be attended by a SBA at the time of delivery and were 8 percentage points more likely to give birth at a medical facility as opposed to birthing at home. I find no evidence of impact on take up of prenatal and post-natal check-ups. The use of Community Midwives may be a cost effective tool to reduce maternal deaths, especially for developing countries with low health budgets., (© 2022 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Background: Maternity care in Australia is predominantly provided by midwives, many who give birth. There is a paucity of research on midwives' own childbearing preferences and experiences., Aim: To explore midwives childbirth preferences and outcomes when giving birth to their first child in Australia, after qualifying as a midwife., Methods: An online national survey. Data were analysed using descriptive statistics., Findings: 447 midwives responded, with the majority of midwives indicating a preference for a normal vaginal birth with a known care provider under a continuity of midwifery care model. For midwives who were first time mothers, 66% had normal vaginal births, 16.3% had an instrumental birth, and 16.8% had caesarean births. Over 85% of midwives received the model of care they wanted and 45% had continuity of midwifery care. While a quarter of midwives wanted a homebirth,11.2% achieved this. Over three quarters (75.4%) of midwives were cared for by a care provider of their choosing., Discussion: There was a difference in models of care accessed and birth outcomes between midwives and other women giving birth for the first-time in Australia. Australian midwives appear to have the advantage of clinical and scientific knowledge to navigate the maternity care system to get the birth care and outcomes they want., Conclusion: It is possible that professional experience, insider knowledge, and existing relationships with other midwifery friends and colleagues, affords midwives a higher degree of agency and autonomy when it comes to getting the maternity care and birth outcomes that they want., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Problem: The COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values., Background: Healthcare professionals' stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic., Aim: To explore midwives' experiences of providing care to women and families during the COVID-19 pandemic., Methods: Qualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained., Findings: Four themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness., Discussion: Midwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork., Conclusion: In the context of a pandemic, optimisation of midwives' physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event., Competing Interests: Conflict of interest None declared., (Copyright © 2023 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Due to the cultural diversity in South Africa, midwives are challenged to provide culturally competent, congruent, and sensitive maternal care. Using a qualitative descriptive design, this study aimed to explore and describe the experiences of midwives providing culturally competent care to women receiving maternal care within overburdened public hospitals. Purposive sampling of thirty-four (n = 34) midwives employed to provide maternal care (antenatal, intrapartum, and postpartum) at five public hospitals in the North West Province of South Africa was done. Semi-structured interviews were conducted in English and transcribed verbatim. Data was analysed thematically with the assistance of an independent co-coder. Data revealed that midwives viewed communication as a key component of cultural competence. Midwives do not necessarily understand the concept "cultural competence." It is recommended that a policy of culturally competent maternal care be developed and implemented by midwives in practice., 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 © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aim: To identify and understand the scope of the literature published since January 2008 that explored Australian midwives understanding of cultural safety and how this is translated into their practice when caring for First Nations women and families., Background: Recognition and understanding of First Nations peoples history and culture and the impact this has on the health and wellbeing of women and their families is essential if the midwife is to promote culturally safe and respectful maternity care. The role and responsibilities of the midwife in ensuring that their practice is culturally safe are now reflected in the Australian professional midwifery codes and standards. Whilst midwifery academics' awareness of cultural safety and how it is taught within midwifery education programs have previously been explored, at present, little is known about midwives' understanding of cultural safety, and how this translates into their clinical practice., Methods: A Scoping Review was undertaken following Arksey and O'Malley's five step process. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses - Scoping Review extension checklist. Twelve studies met the criteria for inclusion. Thematic analysis was used to analyse the data and organise the results., Results: Thematic analysis, guided by two predetermined review questions led to the identification of six overarching themes: 'Awareness of deficiencies', 'The importance of meeting women's diverse needs', 'Understanding relationships as a foundation for culturally safe care', 'Working in partnership with others', 'Providing individualised care' and 'Fostering effective relationships and communication'. One sub-theme of the first theme was identified, this was named 'Seeking an understanding of culture'., Conclusion: Australian midwives' level of understanding of cultural safety and how it is translated into their midwifery practice when caring for First Nations women and their families differ widely. Midwives across Australia require increased and equitable access to appropriate opportunities to improve their knowledge and understanding of cultural safety. Whilst theoretical learning on cultural safety has a place in all midwives annual mandatory training requirements, this should ideally be supplemented, where possible, with opportunities for immersive practice in communities. Immersion was considered the optimal way to gain rich knowledge and understanding to strengthen culturally safe midwifery practice. Continuity models of midwifery care which incorporate the principles of cultural safety should be consistently implemented across Australia. These models enable midwives, women, families, communities, and Aboriginal Support Workers to work in collaboration towards achieving optimal outcomes for mothers and babies., Study Registration: N/A., 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 © 2022 Elsevier Ltd. All rights reserved.)

Background and Purpose: Team-based care has been proposed as a means of improving maternity care in the United States. Methods: The study evaluated the individual and group-level psychometric properties of the Collaborative Practice Scale (CPS) among 108 midwives and physicians who provided team-based care in military hospitals. Results: Psychometric properties of the CPS included Cronbach's alpha of .98. Internal consistency was measured with item-to-total correlations from .83 to .94 and inter-item correlations from .71 to .88. Principal components analysis resulted in a single-factor loading, accounting for 80% of total variance. Properties of the scale at the group level; strong within team agreement ( r wg( j ) = .94) and between team variance (ICC1 = .15, ICC2 = .65). Conclusion: The CPS demonstrated reliability and validity of the instrument at the individual and group levels. The collaborative process can be measured among midwife-physician teams., (© Copyright 2022 Springer Publishing Company, LLC.)

Objective: To explore knowledge, experiences and attitudes of midwives in maternity care in encounters with pregnant women with obesity, and whether they investigate adverse childhood experiences as a contributing factor to the weight challenges., Design: Semi-structured interviews were undertaken to explore midwives' experiences of providing maternity care for women with obesity. For data analysis, Malterud's systematic text condensation was used, a method for thematic cross-case analysis of qualitative data with an inductive approach., Participants and Setting: Nine midwives working in maternity care in Central Norway. The interviews were conducted online or at the midwives' workplace., Findings: The midwives routinely investigated pregnant women's childhood, but few saw a link between adverse childhood experiences and obesity. Pregnant women with obesity were perceived by the midwives as particularly vulnerable, which led to a sensitive, individualised approach focusing on trust and relationship building. This approach, in addition to pointing out complications that can occur with obesity, was described as a balancing act. The midwives described preventative healthcare as a natural task, but hectic days with many competing tasks were seen as an obstacle. The women's motivation for lifestyle change was experienced differently by the midwives; some described strong motivation while others mentioned poor motivation. The midwives found it reassuring to have experience to draw on in broaching difficult topics., Key Conclusions and Implications for Practice: Midwives' many years of experience enable them to approach obese pregnant women in an individual and careful way. Their mission in public health could be better utilised if they explored negative childhood experiences in relation to pregnant women's weight challenges., 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 © 2022. Published by Elsevier Ltd.)

Background: There is an overuse of cardiotocography for intrapartum fetal monitoring for low-risk women in high-income countries, despite recommendations from evidence-based guidelines., Aim: To understand why midwives use cardiotocography for low-risk women despite evidence-based recommendations and to understand the roles of the cardiotocograph machine., Method: This qualitative study used focus groups for data collection. Thirty-one midwives and three student midwives participated from four different countries: New Zealand, Australia, Denmark, and Norway. Constant comparative analysis, informed by an actor-network theory framework, was the method of data analysis., Findings: Cardiotocography was multifaceted and influenced all attendants in the birth environment. The cardiotocograph itself is assigned different roles within the complex networks surrounding childbirth. The cardiotocograph's roles were as a babysitter, the midwives' partner, an agent of shared responsibility, a protector that 'covers your back', a disturber of normal birth, and a requested guest., Discussion: The application of the actor-network theory enabled us to understand how midwives perceive cardiotocography. The assigned roles of the cardiotocograph shape its everyday use more than evidence-based guidelines. Discussion of these inconsistencies must inform the use of cardiotocography in the care of women with low-risk pregnancies., Conclusion: We found that the cardiotocograph is a multifaceted actant that influences practice by performing different roles. Drawing on this study, we suggest that actor-network theory could be a helpful theoretical perspective to critically reflect upon the increasing use of technologies within maternity care., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In recent years, Disrespectful Maternity Care of women seeking maternity services in the health facilities continues to gain recognition globally, given that it is a violation of women's right. Growing evidence from both low- and high-income countries indicate that many women are discouraged from accessing health facilities due to substandard maternity services and the likelihood of disrespectful and abusive care from midwives and other health providers. This study's aim was to explore midwives' perception of respectful maternity care during childbirth in selected health facilities in Lagos state, Nigeria. The research study employed exploratory descriptive research design. Data generation was through semi structured individual interviews. The data underwent manual coding and thematic analysis. The findings revealed that participating midwives were newly acquainted with the term Respectful Maternity Care (RMC), but they had positive perception of RMC. Midwives perceived RMC as treating patients with dignity and respect, respect of patients' culture, beliefs and values, maintain privacy and confidentiality, respect patients' opinions, and non-abusive care. They also viewed RMC as explaining procedure to obtain consent, holistic and individualised care, client/relations involvement in care, empathic care, non-abandonment and non-discriminatory care. Findings further revealed that perceptions do not fully translate into practice.

Background: Australia experienced a low prevalence of COVID-19 in 2020 compared to many other countries. However, maternity care has been impacted with hospital policy driven changes in practice. Little qualitative research has investigated maternity clinicians' perception of the impact of COVID-19 in a high-migrant population., Aim: To investigate maternity clinicians' perceptions of patient experience, service delivery and personal experience in a high-migrant population., Methods: We conducted semi-structured in-depth interviews with 14 maternity care clinicians in Sydney, New South Wales, Australia. Interviews were conducted from November to December 2020. A reflexive thematic approach was used for data analysis., Findings: A key theme in the data was 'COVID-19 related travel restrictions result in loss of valued family support for migrant families'. However, partners were often 'stepping-up' into the role of missing overseas relatives. The main theme in clinical care was a shift in healthcare delivery away from optimising patient care to a focus on preservation and safety of health staff., Discussion: Clinicians were of the view migrant women were deeply affected by the loss of traditional support. However, the benefit may be the potential for greater gender equity and bonding opportunities for partners. Conflict with professional beneficence principles and values may result in bending rules when a disconnect exists between relaxed community health orders and restrictive hospital protocols during different phases of a pandemic., Conclusion: This research adds to the literature that migrant women require individualised culturally safe care because of the ongoing impact of loss of support during the COVID-19 pandemic., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Background: The COVID-19 pandemic has impacted the provision of maternity care worldwide. The continuation of maternity services during the pandemic is vital, but midwives have reported feeling overwhelmed in providing these services at this time. However, there are limited studies in Indonesia that have explored the experiences of midwives in providing care during the pandemic., Aim: Our study aims to explore Indonesian midwives' experiences in providing maternity care during the COVID-19 pandemic., Methods: We used a descriptive qualitative approach using in-depth interviews to explore the experiences of 15 midwives working in different level of maternity care facilities in two regions in Indonesia, Surabaya and Mataram. All interviews were conducted via WhatsApp call and were audio-recorded with permission. Data were analysed using inductive thematic analysis., Findings: Four themes were identified: 1) fear for the wellbeing of the family and herself, 2) increased workload, 3) motivation and support for midwives, and 4) challenges in providing maternity care for women., Discussion: Sense of duty and loyalty to other midwives motivated midwives to continue working despite their fears and increased workload. Inadequate protection and support and practical challenges faced by midwives should be addressed to ensure midwives' wellbeing and the continuity of maternity care., Conclusion: Our study provides insight into Indonesian midwives' experiences in providing maternity care during the COVID-19 pandemic. Adequate protection through PPE availability, effective training and support for midwives' wellbeing is needed to support midwives in providing maternity care during the pandemic. Community's adherence to COVID-19 protocols and good collaboration between primary health centres and hospitals would also benefit midwives., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Aim: To analyze the concept of maternal caring ability for a preterm infant to develop an operational definition., Background: Each year, many newborns are born preterm and admitted to the neonatal intensive care unit (NICU). Although their mothers are prepared for discharge home by the staff, it is difficult to identify an operational definition of their maternal caring ability for the preterm infant., Design: Concept analysis., Data Sources: Searches used PubMed, as the primary health-related literature, ProQuest, Science Direct, CINHAL, web of science, Scopus, and Google Scholar. Keywords caring ability, mother, and preterm infant were used to analyze the development of the concept from 1965 to 2020., Methods: Rogers' and Knafl's evolutionary approach has been used to explain the concept of maternal caring ability for the preterm infant., Results: The combined searches yielded 23,291 documents published in English. After the screening process, 43 documents were selected. The Graneheim and Lundman analysis method was used to identify the themes related to the attributes of maternal caring ability. Findings showed the caring ability to have four antecedents (maternal characteristics, support systems, infant characteristics, and the illness severity), four attributes (knowledge and skill in neonatal care, self-efficacy, sensitivity, responsibility, and problem-solving), and three consequences (parental adjustment, improving infant growth and development, and improving parent-infant relationships)., Conclusion: The caring ability of the mother of a preterm infant is grounded in an adequate knowledge of caregiving needs of a preterm infant, high caregiving skills, a sense of self-efficacy, problem-solving, sensitivity, and responsibility., (© 2022 Wiley Periodicals LLC.)

Aims: Although there is substantial literature on autonomy of midwifery, the concept remains vague, and what it exactly constitutes is little clear. Attempts to define this have been carried out, but did not result in a communal understanding. The aim of this study therefore was to define a consistent definition of midwifery autonomy in Belgium., Design: A modified Delphi survey with content experts., Methods: Critical components of the available definitions on midwifery autonomy were retrieved from the literature, and translated into Dutch and French. An online Delphi panel of content expert assessed components of autonomy in midwifery on clarity and relevance between June and October 2021. From the validated components, a preliminary consolidated definition was generated, which was validated in a final Delphi round., Results: After round one, content experts (n = 27) evaluated 10 out of 17 components to be clear and relevant. Two components were judged inappropriate and therefore removed. After further adaptation four additional components were identified appropriate after the second round, and one component after a third Delphi round. Experts' suggestions for improving the clarity and relevance were taken into account. Finally, experts assessed the preliminary definition. After minor modifications the definition of midwifery autonomy in Belgium was confirmed valid., Conclusion: We established a communal definition of midwifery autonomy in Belgium, the creation of such a definition results in a joint understanding of the concept of midwifery autonomy., Impact: If midwives internationally want to successfully achieve autonomy, a clear understanding of the concept of midwifery autonomy is needed. The consensus definition of midwifery autonomy in Belgium comprises 15 components related to midwives' work content, professionalism and relationship with others. Our definition of midwifery autonomy has the potential to encourage an international dialogue, grounded in a common understanding of autonomy, enabling stakeholders in maternity care to strengthen professional midwifery autonomy., (© 2022 John Wiley & Sons Ltd.)

Background: Around one in three women experience sexual violence during their lifetime. They may need trauma-sensitive maternity care that takes sexual trauma triggers into account. Midwives are similarly likely to have experienced sexual violence in their lifetime. It is unknown whether midwives with a personal sexual violence history have a different professional approach to the topic than their colleagues without such history., Aim: To explore whether midwives with a personal sexual violence history are more likely to have received or need education about sexual violence and whether they approach sexual violence differently in practice., Methods: An exploratory online survey was conducted amongst practicing midwives in high resource countries. Odds ratios were calculated for differences between midwives with and without a personal sexual violence history., Findings: Of the 288 participating midwives, 48.6% disclosed a personal sexual violence history. Midwives with a personal sexual violence history showed higher uptake of post-graduate education (OR 2.05, 95% CI 1.23-3.44), more accurate prevalence estimation (OR 3.42, 95% CI 2.10-5.57) and more confidence to identify sexual violence history (OR 1.94, 95% CI 1.19-3.15). We found no differences in requiring future education, screening practices, other aspects of confidence or time and discomfort barriers., Conclusions: As fellow survivors, midwives with a personal sexual violence history have a unique standpoint towards sexual violence in maternity care practice that may make them more sensitive to the issue., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The majority of maternity care is provided by female midwives who have either become mothers or are of childbearing age, but there is limited research exploring midwives' own personal childbearing experiences. This integrative review aims to explore the published literature and research on midwives' own experiences of pregnancy and childbirth., Method: An integrative review of the literature was conducted after relevant articles were identified through a search of: five electronic databases (Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar), cited reference lists, and networking with peers. Similar and contrasting patterns and relations within the literature were identified and grouped into themes and subthemes., Results: Twenty articles were included in the review and four overarching themes were identified. Insider knowledge plays a role in decision making encompassed the way midwives used their knowledge to choose; a preferred mode of birth, maternity care provider, model of care, and place of birth. Navigating the childbirth journey demonstrated how some midwives were able to use their insider knowledge to achieve agency, while others had difficulty achieving agency. This theme also revealed the 'midwife brain' that midwives need to manage during their childbearing journey. The theme impact of care on the birth experience described how the type of care the midwives received from maternity care providers affected their overall birth experience. The fourth theme from midwife to mother explains their preparedness for childbirth and their transition to motherhood., Conclusion: For childbearing midwives, there is a potential conflict between their position as knowledgeable experts in maternity care, and their experience as mothers. Whilst they can use their insider knowledge to their advantage, they also experience heightened fear and anxiety through their pregnancy. It is important for maternity care providers to acknowledge and support them and provide balanced and tailored care that acknowledges the woman within the professional midwife and the professional midwife within the woman., (© 2022. The Author(s).)

Background: Mental disorders such as depression and anxiety are common during pregnancy and postpartum, but are frequently underdiagnosed and untreated. In the last decades, internet-based interventions have emerged as a treatment alternative showing similar effectiveness to face-to-face psychotherapy. We aimed to explore midwives' perceptions of the acceptability of internet-based interventions for the treatment of perinatal depression and anxiety symptoms., Methods: In this ethnographic qualitative study, semi-structured interviews were conducted with 30 midwives. We followed the Consolidated Criteria for Reporting Qualitative Research Checklist (COREQ). Audio-recorded interviews were transcribed verbatim and analysed using framework analysis. The identified framework categories were rated individually by two independent raters. Krippendorff's alpha coefficient was used to ensure the reliability of the rating., Results: Four main themes emerged: midwives' experience with patients' mental health issues; the role of healthcare workers in women's utilisation of internet-based interventions in the perinatal period; the overall perception of internet-based interventions; and recommendation of internet-based interventions to perinatal women. Twenty-five of the 30 participants viewed internet-based interventions as an acceptable type of intervention, which they would recommend to a subgroup of patients (e.g. women who are well-educated or younger). All except for two midwives identified themselves and medical doctors as key figures regarding patients' utilisation of internet-based interventions, although a third of the interviewees highlighted that they needed sufficient information about such interventions. Finally, several participants suggested features which could be relevant to develop more acceptable and feasible internet-based interventions in the future., Discussion: Participants' overall perception of internet-based interventions for perinatal depression and anxiety symptoms was positive. This study underlines the importance of considering midwives' views about internet-based interventions for perinatal mental health care. Our findings have implications for the practice not only of midwives but also of other maternity care professionals. Future studies examining the views of other health professionals are warranted., (© 2022. The Author(s).)

Background: Postpartum haemorrhage (PPH) is one of the major complications of childbirth which may result in maternal morbidity and mortality, especially in low and middle-income countries like Nigeria. Midwives play a vital role in preventing and managing PPH in Nigerian rural communities. The aim of this study is to understand the experiences of midwives in rural maternity care settings in order to provide appropriate support and improve practice., Methods: An exploratory, qualitative study of a purposive sample of 15 practicing midwives was carried out using semi-structured interviews from November 2018 to February 2019. Data were transcribed verbatim and analyzed using content analysis., Results: Four themes were identified: 1. interventions for preventing PPH; 2. approaches to managing PPH; 3. challenges of preventing and managing PPH and 4. ways of supporting midwives to overcome these challenges in rural health care settings. Midwives employed various strategies, such as antenatal education, diagnosis and treatment of anaemia to counteract complications from possible PPH. Understanding PPH as a life-threatening condition enabled the midwives to provide holistic and effective management that sometimes involved a multidisciplinary team approach. Inadequate resources and delay in seeking health care, however, militate against their efforts. The midwives also identified the need for continuing education and training to enhance their standards of care., Conclusion: These midwives in Nigerian rural health care settings engage in preventive practices and active management of PPH though not without barriers, such as inadequate resources. There is a need for midwives in rural areas to have cultural competence, be provided with adequate resources and participate in ongoing education in order to be more effective., (© 2022. The Author(s).)

Objective: To identify the challenges and opportunities for rolling out a bespoke model of group antenatal care called Pregnancy Circles (PC) within the National Health Service: what kind of support and training is needed and what adaptations are appropriate, including during a pandemic when face-to-face interaction is limited., Design: Exploratory qualitative study (online focus group). Study co-designed with midwives. Data analysed thematically using an ecological model to synthesise., Setting: Five maternity services within the National Health Service., Participants: Seven midwives who facilitated PCs. Three senior midwives with implementation experience participated in the co-design process., Findings: Three themes operating across the ecological model were identified: 'Implementing innovation', 'Philosophy of care' and 'Resource management'. Tensions were identified between group care's focus on relationships and professional autonomy, and concepts of efficiency within the NHS's market model of care. Midwives found protected time, training and ongoing support essential for developing the skills and confidence needed to deliver this innovative model of care. Integrating Pregnancy Circles with continuity of carer models was seen as the most promising opportunity for long-term implementation. Midwives perceived continuity and peer support as the most effective elements of the model and there was some evidence that the model may be robust enough to withstand adaptation to online delivery., Key Conclusions: Midwives facilitating group care enjoyed the relationships, autonomy and professional development the model offered. Harnessing this personal (micro-level) satisfaction is key to wider implementation. Group care is well aligned with current maternity policy but the challenges midwives face (temporal, practical and cultural) must be anticipated and addressed at macro and meso level for wider implementation to be sustainable. The PC model may be flexible enough to adapt to online delivery and extend continuity of care but further research is needed in these areas., Implications for Practice: Implementation of group care in the NHS requires senior leadership and expertise in change management, protected time for training and delivery of the model, and funding for equipment. Training and ongoing support, are vital for sustainability and quality control. There is potential for online delivery and integrating group care with continuity models., Competing Interests: Conflict of 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 © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Evidence shows that women in Ghana experience disrespectful care (slapping, pinching, being shouted at, etc.) from midwives during childbirth. Hence, evidence-based research is needed to advance the adoption of respectful maternity care (RMC) by midwives. We therefore sought to explore and document midwives' perspectives concerning challenges faced and prospects available for promoting RMC in a tertiary health facility., Methods: We employed an exploratory descriptive qualitative study design. In total, we conducted 12 interviews with midwives educated on RMC. All audio data were transcribed verbatim and exported to NVivo-12 for data management and analyses. We relied on the Consolidated Criteria for Reporting Qualitative Research guideline in reporting this study., Results: The findings were broadly categorised into three themes: emotional support, dignified care and respectful communication which is consistent with the WHO's quality of care framework. For each theme, the current actions that were undertaken to promote RMC, the challenges and recommendations to improve RMC promotion were captured. Overall, the current actions that promoted RMC included provision of sacral massages and reassurance, ensuring confidentiality and consented care, and referring clients who cannot pay to the social welfare unit. The challenges to providing RMC were logistical constraints for ensuring privacy, free movement of clients, and alternative birthing positions. Poor attitudes from some midwives, workload and language barrier were other challenges that emerged. The midwives recommended the appointment of more midwives, as well as the provision of logistics to support alternative birthing positions and privacy. Also, they recommended the implementation of continuous training and capacity building., Conclusion: We conclude that in order for midwives to deliver RMC services that include emotional support, dignified care, and respectful communication, the government and hospital administration must make the required adjustments to resolve existing challenges while improving the current supporting activities., (© 2022. The Author(s).)

Background: The COVID-19 (coronavirus disease 2019) pandemic challenges provision and access to essential maternity care in low-resilience health systems. The aim of this study was to explore maternity healthcare workers' experiences of, and perceptions about providing maternity care during the COVID-19 outbreak in Lagos State, Nigeria., Methods: This qualitative study conducted individual, remote, semi-structured interviews with midwives and traditional birth attendants (TBAs). Eligible participants spoke English, and provided maternity care during COVID-19 in Lagos, Nigeria. Participants were recruited via purposive and snowball sampling, from primary health facilities in seven Local Government Areas of Lagos State. Interview transcripts were analysed thematically following the framework method., Results: Sixteen midwives (n = 11) and TBAs (n = 5) were interviewed from March to April 2021. Two overarching themes were identified from the data. 'Maternity care workers' willingness and ability to work during the COVID-19 pandemic' outlined negative influences (fear and uncertainty, risk of infection, burnout, transport difficulties), and positive influences (professional duty, faith, family and employer support). Suggestions to improve ability to work included adequate protective equipment, training, financial support, and workplace flexibility. 'Perceived impact of COVID-19 on women's access and uptake of maternity care' highlighted reduced access and uptake of antenatal and immunisation services by women. Challenges included overstretched health services, movement and cost barriers, and community fear of health facilities. Participants reported delayed healthcare seeking and unattended home births. Midwives and TBAs identified a need for community outreach to raise awareness for women to safely access maternity services. Participants highlighted the responsibility of the government to improve staff welfare, and to implement public health campaigns., Conclusions: Despite disruption to maternity care access and delivery due to COVID-19, midwives and TBAs in Lagos remained committed to their role in caring for women and babies. Nevertheless, participants highlighted issues of understaffing and mistrust in Lagos' underfunded maternity care system. Our findings suggest that future resilience during outbreaks depends on equipping maternity care workers with adequate working conditions and training, to rebuild public trust and improve access to maternity care., (© 2022. The Author(s).)

Problem: COVID-19 guidance from professional and health organisations created uncertainty leading to professional and personal stress impacting on midwives providing continuity of care in New Zealand (NZ). The COVID-19 pandemic resulted in massive amounts of international and national information and guidance. This guidance was often conflicting and not suited to New Zealand midwifery., Aim: To examine and map the national and international guidance and information provided to midwifery regarding COVID-19 and foreground learnt lessons for future similar crises., Methods: A systematic scoping review informed by Arksey and O'Malley's five-stage framework. A range of sources from grey and empirical literature was identified and 257 sources included., Findings: Four categories were identified and discussed: (1) guidance for provision of maternity care in the community; (2) guidance for provision of primary labour and birth care; (3) Guidance for midwifery care to women/wāhine with confirmed/suspected COVID-19 infection, including screening processes and management of neonates of infected women/wāhine (4) Guidance for midwives on protecting self and own families and whānau (extended family) from COVID-19 exposure., Conclusion: Guidance was mainly targeted and tailored for hospital-based services. This was at odds with the NZ context, where primary continuity of care underpins practice. It is evident that those providing continuity of care constantly needed to navigate an evolving situation to mitigate interruptions and restrictions to midwifery care, often without fully knowing the personal risk to themselves and their own families. A key message is the need for a single source of evidence-based guidance, regularly updated and timestamped to show where advice changes over time., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Problem: The COVID-19 pandemic has required rapid and radical changes to the way maternity care is provided in many nations across the world., Background: Midwives provide care to childbearing women across the continuum and are key members of the maternity workforce in Australia., Aim: To explore and describe midwives' experiences of providing maternity care during the COVID-19 pandemic in Australia., Methods: A two-phased cross-sectional descriptive study was conducted. Data were collected through an online survey and semi-structured interviews between May-June 2020., Findings: Six hundred and twenty midwives responded to the online survey. Many reported a move to telehealth appointments. For labour care, 70% of midwives reported women had limited support; 77% indicated postnatal visiting was impacted. Five main themes were derived from the qualitative data including: coping with rapid and radical changes, challenges to woman-centred care, managing professional resilience, addressing personal and professional challenges, and looking ahead., Discussion: Restrictions applied to women's choices, impacted midwives' ability to provide woman-centred care, which resulted in stress and anxiety for midwives. Professional resilience was supported through collaborative relationships and working in continuity models. Midwives revealed 'silver linings' experienced in providing care during the pandemic., Conclusion: Findings provide valuable evidence to understand the impact on midwives who have provided care during the COVID-19 pandemic. Knowledge will be useful for health leaders and policy makers as they consider ways to continue care during the pandemic and support the essential midwifery workforce. Recommendations are presented to improve preparedness for future pandemics., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objective: To explore how COVID-19 influenced the provision of high-quality maternity care in Indonesia., Design and Methods: A qualitative descriptive study using in-depth interviews was undertaken. Thematic analysis was used to analyse data, and behaviour change frameworks (Theoretical Domain Framework (TDF) and Capability, Opportunity, and Motivation (COM-B)) were used to identify and map facilitators and barriers influencing maternity care provision during the COVID-19 pandemic., Setting and Participants: Fifteen midwives working in community maternity care facilities in Surabaya and Mataram, Indonesia were included. Surabaya is in western Indonesia, with around 56,000 births per year and a population of around 3 million. Mataram is in eastern Indonesia, with around 7,000 births per year and a population of around 500,000., Findings: The main changes to maternity care provision during the COVID-19 pandemic were reduced frequency of antenatal and postpartum care visits, reduced support for women, including unavailability of maternity care and reduced number of antenatal care and labour companions, changes in location of provision of care, and public health changes related to COVID-19. The main factors influencing the provision of high-quality maternity care during the COVID-19 pandemic were behavioural regulation, professional role and identity, and environmental context and resources., Key Conclusions and Implications for Practice: Maternity care provision underwent substantial changes during the COVID-19 pandemic in Indonesia. Findings from this study can contribute to better understanding of how maternity care provision changed during the pandemic, and how positive changes can be reinforced, and negative changes can be addressed., 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 © 2022. Published by Elsevier Ltd.)

Background:  'Doing what the Romans do in Rome' was an expression raised by one of the midwives following workplace culture and disregarding women's birth choices. Midwifery practice in South Africa caters for a culturally diverse ethnic groups of childbearing women. Culturally appropriate care highlights the importance of including women in decision-making concerning their birth preferences including maternal positions during labour. Women's right to choose their maternal position and cultural preferences during labour has been overlooked, leading to poor maternal healthcare provision and negative birth experiences., Aim:  In this article, the researchers aimed to describe and explore midwives' perspectives on culturally appropriate care to support maternal positions during the second stage of labour., Setting:  Midwives working in the maternity ward in a public hospital in South Africa., Methods:  A qualitative descriptive design using individual interviews was used to collect data. The participants were selected using the purposive sampling method. The study population comprised 20 midwives who volunteered to participate in the study. Data were transcribed manually and analysed using thematic analysis., Results:  The four main themes are as follows: (1) Caring for women from various ethnic groups, (2) midwives disregard women's beliefs and culture, (3) midwife personal cultural attributes and (4) midwifery unit workplace culture., Conclusion:  The authors concluded that culturally appropriate care towards the women's choices of birth position during the second stage of labour should form an integral part of the midwifery care rendered.

Objective: This study aimed to explore Vietnamese midwives' experiences of working in maternity care., Methods: A descriptive qualitative study was undertaken, which involved four focus group discussions with midwives (n = 25) working at three different hospitals in urban, semi-urban and rural parts of Hanoi region, Vietnam. Data were analysed using qualitative content analysis., Results: The overall theme, "Practising midwifery requires commitment" showed that Vietnamese midwives' dedication to their work and to women's reproductive health helped them to cope with stress, pressure and negative aspects of their work environment. In the first category "Being the central link in the web of care", midwives described themselves as having a key role in maternity care although collaborations with other health professions were important. In the second category "Rewarding role but also vulnerable position", positive aspects of midwifery were expressed although the great pressure of the work midwives do was prominent. High workload, patients' demands, and being negatively exposed and vulnerable, when adverse events occurred, were reported. In the third category "Morally challenging tasks", ultrasound examinations to reveal fetal sex and working with abortion services were described as emotionally stressful., Conclusions: Although participating Vietnamese midwives experienced midwifery as essentially positive, they felt exposed to significant workload pressure, ethically highly demanding work and being blamed when adverse obstetric events occurred. Public health interventions to inform Vietnamese citizens about reproductive issues, as well as specific antenatal education measures may increase the understanding of evidence-based maternity care and complications that can occur during pregnancy and birth., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: In depth exploration of the burnout phenomenon among midwives is sparse. The concept has been extensively studied, but predominantly reports rates and evaluates interventions to reduce burnout. A definition has yet to be offered in the literature from a midwifery perspective., Aims: To explore midwives' understandings of burnout, professionally and personally, in the context of contemporary maternity care in Ireland., Methods: This was a Two-phase Participatory Action Research study. Five co-operative inquiry meetings were held with practising midwives (n=21) over a six-month period between October 2018 and March 2019, in a large, urban teaching maternity hospital in Dublin, Ireland., Findings: We found that multiple factors contributed to midwives' perceptions and understandings of the concept of burnout. Midwives defined burnout as persistent stress and exhaustion, with an associated reduction of their individual coping abilities, motivation, empathy and/or efficacy, is unique to the individual and is primarily, in the midwifery context, caused and inextricably linked to excessive workload., Conclusion: Burnout is a complex concept with many entities and its significance and impact within the midwifery profession highlights the importance of its exploration and understanding. This study is the first of its kind to explore, with midwives, the concept of burnout. The elements of stress and exhaustion in the definition mirror existing definitions in the literature., (Copyright © 2021 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Background: Growing evidence shows that many parents begin the decision-making process about infant vaccination during pregnancy and these decisions - once established - may be resistant to change. Despite this, many interventions targeting vaccination are focused on communicating with parents after their baby is born. This suggests that the prenatal period may constitute a missed opportunity for communicating with expectant parents about infant vaccination., Methods: Using a longitudinal qualitative design, we conducted two interviews (prepartum and postpartum) with women (n = 19) to explore the optimal timing of vaccination information. The data were analyzed thematically, and examined across all sets of pre- and post-partum interviews as well as within each individual participant to draw out salient themes., Results: Most participants formed their intentions to vaccinate before the baby was born and indicated that they would welcome information about vaccination from their maternity care providers. However, few individuals recalled their maternity care providers initiating vaccination-related conversations with them., Conclusion: The prenatal period is an important time to begin conversations with expectant parents about vaccinating their infants, particularly if these conversations are initiated by trusted maternity care providers. More information is needed on how maternity care providers can be better supported to have these conversations with their patients., (© 2022. The Author(s).)

Background: Rural and remote Australian women are less able to access locally situated maternity care and birthing facilities, largely due to the gradual closures of rural and remote birthing services. Closures have occurred due to workforce issues, safety and quality issues and economic rationalisation of services to offset rising health system costs. An examination of the published literature to gain a deeper understanding of this phenomenon is warranted., Question: What are the impacts of rural and remote maternity unit closures in Australia?, Methods: A systematic integrative review of published literature on Australian maternity unit closures was undertaken using Whittemore and Knafl's (2005) framework. A database search was conducted with date limiters of 2010 to 2020 on papers within the search parameters "maternity unit*" AND closure* AND women AND (midwife OR midwives) AND Australia, also with "birth unit", "labour ward" and "rural" in varying combinations. This search resulted in 348 papers. After applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process and the Crowe Critical Appraisal Tool (CCAT) and discarding those non-relevant, seven papers remained., Findings: A methodological analysis of seven papers occurred, three qualitative studies, three quantitative studies and one mixed methods study. Two main stakeholders were identified, the woman, and the health service. Women identified risks associated with travel, lack of access to services, costs or financial issues, safety, and emotional burdens. Women explicitly stated that access to local maternity services would negate many of their concerns. Health services indicated closures were due to safety and quality considerations and workforce issues., Conclusion: Conflict exists in trying to meet the perceived needs of both stakeholder groups. Published evidence supports midwifery models for low-risk women. National policy also supports woman-centred care; however, local service uptake is minimal due to organisational barriers., Competing Interests: Declaration of Competing Interest There were no conflicts of interest when writing this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Objective: Engagement of fathers to participate in pregnancy, birth and early postnatal care has significant advantages for women and infants as well as fathers. In Australia, guidelines for midwifery practice do not include specific recommendations about father-inclusive care, and models for publicly funded maternity care do not extend to the provision of care tailored specifically towards the needs of fathers. This study investigated the perceptions of midwives regarding their role in fathers' wellbeing, the extent of fathers' attendance at and participation in their services, advantages and disadvantages of father participation and barriers and enablers to father engagement., Design: Convergent mixed methods, cross-sectional., Setting: A large metropolitan public maternity hospital that provides care to some of the most socio-economically disadvantaged suburbs and multi-cultural communities in Melbourne, Australia., Participants: All midwives employed at the hospital (n=196) were invited to participate., Methods: Anonymous online survey and semi-structured interviews. Descriptive statistics were calculated for quantitative survey responses. Interview data and qualitative survey responses were analysed thematically., Findings: Forty midwives working in all areas of maternity services across the hospital completed surveys, and six participated in interviews. The data illustrate the dilemma faced by midwives in their specific role of supporting women and babies. On the one hand, participants indicated that fathers' wellbeing should be part of their role and named many advantages of father participation in maternity services, including support and advocacy for mothers and bonding with infants. Participants estimated that most fathers attend births and visit their partner and infant on the postnatal ward, 52% attend antenatal appointments and 76% are present at postnatal home visits. Participants reported several midwife strategies and health service factors which facilitate father attendance and active engagement. On the other hand, participants reported several barriers to father engagement, including antenatal appointment schedules which are at odds with fathers' work commitments and the lack of on-site group antenatal education. Some of the barriers they reported are specific to the vulnerable communities for which they provide maternity care. Extraordinary circumstances were reported, including fathers working overseas, fathers in prison, new immigrant status that is often accompanied by a lack of family support to care for other children even during labour and birth, and poor socio-economic status. In addition, in many cultures, pregnancy and birth are seen as "women's work"; fathers would not traditionally be involved. Participants also reported that midwives lack training and confidence in engaging fathers, particularly in responding to fathers with mental health concerns. When providing care for families at risk of family violence, father attendance was perceived a significant disadvantage., Key Conclusions: Midwife-provided health services represent a significant opportunity to include and address fathers, and midwives recognise the significant advantages of engaging fathers, unless there is a risk of family violence. However, midwives currently report lack of training and confidence in addressing fathers' needs, and several individual, social, cultural, and health service factors can present barriers to engaging fathers., Implications for Practice: Given the substantial benefits of engaging fathers for women and infants, we argue that maternity services should promote father engagement, for example by offering after hours appointment schedules, free antenatal and parenting education, and workshops to upskill midwifery staff. Education regarding the importance of father participation and skills for working with fathers should be included in the undergraduate preparation of midwives and other key maternity care professionals. Addressing the challenges of providing care to a multicultural community requires sensitive discussion with families from each of those cultures., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2021. Published by Elsevier Ltd.)

Objectives: To explore midwives' and obstetricians' views about community-based bilingual doula (CBD) support during migrant women's labour and birth and their experiences of collaborating with CBDs., Study Design: A qualitative study with semi-structured individual interviews with 7 midwives and 4 obstetricians holding clinical positions in labour care in Stockholm, Sweden, who all had experiences of working with a CBD. Data analysis followed the framework of thematic analysis., Results: The overarching theme was A new actor filling gaps in labour care - With appropriate boundary setting, CBDs can help improve care for migrant women. One year after the introduction of CBDs, the midwives and obstetricians had mainly positive experiences of CBDs who were considered to fill important gaps in maternity care for migrant women, being with the woman and simultaneously being part of the care team and this made providing high quality care easier. The CBDs' main contribution was to help migrant women navigate the maternity care system, to bridge language and cultural divides, and guarantee continuous labour and birth support. However, midwives and obstetricians sometimes experienced CBDs interfering with their professional assessments and decisions and the role of the CBD was somewhat unclear to them., Conclusions: Community-based bilingual doula support was viewed as improving migrant women's well-being during labour and birth and as increasing the possibilities for midwives and obstetricians to provide good and safe care, however, some ambivalence remained about the CBD's role and boundaries., (Copyright © 2021. Published by Elsevier B.V.)

'Medical iatrogenesis' was first defined by Illich as injuries 'done to patients by ineffective, unsafe, and erroneous treatments'. Following Lokumage's original usage of the term, this paper explores 'obstetric iatrogenesis' along a spectrum ranging from unintentional harm (UH) to overt disrespect, violence, and abuse (DVA), employing the acronym 'UHDVA' for this spectrum. This paper draws attention to the systemic maltreatment rooted in the technocratic model of birth, which includes UH normalized forms of mistreatment that childbearers and providers may not recognize as abusive. Equally, this paper assesses how obstetric iatrogenesis disproportionately impacts Black, Indigenous, and People of Color (BIPOC), contributing to worse perinatal outcomes for BIPOC childbearers. Much of the work on 'obstetric violence' that documents the most detrimental end of the UHDVA spectrum has focused on low-to-middle income countries in Latin America and the Caribbean. Based on a dataset of 62 interviews and on our personal observations, this paper shows that significant UHDVA also occurs in the high-income U.S., provide concrete examples, and suggest humanistic solutions.