Jenny Gamble

Maternal role development following childbirth among Australian women.

AIM This paper is a report on the examination of demographic, birthing and social correlates of maternal role development in childbearing women. BACKGROUND Successful adaptation to the maternal role provides a mother with confidence and satisfaction in her ability to nurture and care for her infant. Despite the importance of this developmental process for maternal well-being, little attention has been given to social and demographic predictors of positive role development in recent years. METHODS A prospective study was undertaken at three publicly-funded metropolitan antenatal clinics in Queensland, Australia between March and November 2003. A total of 605 women completed a survey at 36 weeks gestation and 12 weeks postpartum, with a response rate of 78% (n = 473). A self-report questionnaire was used to collect data about personal and birth variables, domestic violence, social support and maternal role development. FINDINGS The majority of women (81%) were of White ethnic background, modal age was 30-45 years (40%, n = 189) and 66 percent (n = 312) were in paid employment. Bivariate analysis identified age, marital status, length of relationship and social support to be statistically significantly associated with maternal role development. Optimal scaling showed social support to be the most important factor in maternal role development. CONCLUSION Maternal role development following childbirth is complex and can be adversely affected by older maternal age, married status, inadequate social support and short partner relationships. A deeper understanding of this process is needed if healthcare professionals are to assist mothers in making a smooth transition to motherhood.

Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and postpartum psychological wellbeing

BackgroundHigh levels of childbirth fear impact birth preparation, obstetric outcomes and emotional wellbeing for around one in five women living in developed countries. Higher rates of obstetric intervention and caesarean section (CS) are experienced in fearful women. The efficacy of interventions to reduce childbirth fear is unclear, with no previous randomised controlled trials reporting birth outcomes or postnatal psychological wellbeing following a midwife led intervention.MethodBetween May 2012 and June 2013 women in their second trimester of pregnancy were recruited. Women with a fear score ≥ 66 on the Wijma Delivery Expectancy / Experience Questionnaire (W-DEQ) were randomised to receive telephone psycho-education by a midwife, or usual maternity care. A two armed non-blinded parallel (1:1) multi-site randomised controlled trial with participants allocated in blocks of ten and stratified by hospital site and parity using an electronic centralised computer service. The outcomes of the RCT on obstetric outcomes, maternal psychological well-being, parenting confidence, birth satisfaction, and future birth preference were analysed by intention to treat and reported here.Results1410 women were screened for high childbirth fear (W-DEQ ≥66). Three hundred and thirty-nine (n = 339) women were randomised (intervention n = 170; controls n = 169). One hundred and eighty-four women (54 %) returned data for final analysis at 6 weeks postpartum (intervention n = 91; controls n = 93).Compared to controls the intervention group had a clinically meaningful but not statistically significant reduction in overall caesarean section (34 % vs 42 %, p = 0.27) and emergency CS rates (18 % vs 25 %, p = 0.23). Fewer women in the intervention group preferred caesarean section for a future pregnancy (18 % vs 30 %, p = 0.04). All other obstetric variables remained similar. There were no differences in postnatal depression symptoms scores, parenting confidence, or satisfaction with maternity care between groups, but a lower incidence of flashbacks about their birth in the intervention group compared to controls (14 % vs 26 %, p = 0.05). Postnatally women who received psycho-education reported that the ‘decision aid’ helped reduce their fear (53 % vs 37 %, p = 0.02).ConclusionFollowing a brief antenatal midwife-led psycho-education intervention for childbirth fear women were less likely to experience distressing flashbacks of birth and preferred a normal birth in a future pregnancy. A reduction in overall CS rates was also found. Psycho-education for fearful women has clinical benefits for the current birth and expectations of future pregnancies.Trial registrationAustralian New Zealand Controlled Trials Registry ACTRN12612000526875, 17th May 2012

Responses to birth trauma and prevalence of posttraumatic stress among Australian midwives

BACKGROUND Midwives frequently witness traumatic birth events. Little is known about responses to birth trauma and prevalence of posttraumatic stress among Australian midwives. AIM To assess exposure to different types of birth trauma, peritraumatic reactions and prevalence of posttraumatic stress. METHODS Members of the Australian College of Midwives completed an online survey. A standardised measure assessed posttraumatic stress symptoms. FINDINGS More than two-thirds of midwives (67.2%) reported having witnessed a traumatic birth event that included interpersonal care-related trauma features. Midwives recalled strong emotions during or shortly after witnessing the traumatic birth event, such as feelings of horror (74.8%) and guilt (65.3%) about what happened to the woman. Midwives who witnessed birth trauma that included care-related features were significantly more likely to recall peritraumatic distress including feelings of horror (OR=3.89, 95% CI [2.71, 5.59]) and guilt (OR=1.90, 95% CI [1.36, 2.65]) than midwives who witnessed non-interpersonal birth trauma. 17% of midwives met criteria for probable posttraumatic stress disorder (95% CI [14.2, 20.0]). Witnessing abusive care was associated with more severe posttraumatic stress than other types of trauma. DISCUSSION Witnessing care-related birth trauma was common. Midwives experience strong emotional reactions in response to witnessing birth trauma, in particular, care-related birth trauma. Almost one-fifth of midwives met criteria for probable posttraumatic stress disorder. CONCLUSION Midwives carry a high psychological burden related to witnessing birth trauma. Posttraumatic stress should be acknowledged as an occupational stress for midwives. The incidence of traumatic birth events experienced by women and witnessed by midwives needs to be reduced.

Midwifery students׳ experiences of an innovative clinical placement model embedded within midwifery continuity of care in Australia

BACKGROUND midwifery continuity of care experiences can provide high quality clinical learning for students but can be challenging to implement. The Rural and Private Midwifery Education Project (RPMEP) is a strategic government funded initiative to (1) grow the midwifery workforce within private midwifery practice and rural midwifery, by (2) better preparing new graduates to work in private midwifery and rural continuity of care models. AIM this study evaluated midwifery students׳ experience of an innovative continuity of care clinical placement model in partnership with private midwifery practice and rural midwifery group practices. METHOD a descriptive cohort design was used. All students in the RPMEP were invited to complete an online survey about their experiences of clinical placement within midwifery continuity models of care. Responses were analysed using descriptive statistics. Correlations between total scale scores were examined. Open-ended responses were analysed using content analysis. Internal reliability of the scales was assessed using Cronbach׳s alpha. FINDINGS sixteen out of 17 completed surveys were received (94% response rate). Scales included in the survey demonstrated good internal reliability. The majority of students felt inspired by caseload approaches to care, expressed overall satisfaction with the mentoring received and reported a positive learning environment at their placement site. Some students reported stress related to course expectations and demands in the clinical environment (e.g. skill acquisition and hours required for continuity of care). There were significant correlations between scales on perceptions of caseload care and learning culture (r=.87 p<.001) and assessment (r=.87 p<.001). Scores on the clinical learning environment scale were significantly correlated with perceptions of the caseload model (rho=.86 p<.001), learning culture (rho=.94 p<.001) and assessment (rho=.65 p<.01) scales. CONCLUSIONS embedding students within midwifery continuity of care models was perceived to be highly beneficial to learning, developed partnerships with women, and provided appropriate clinical skills development required for registration, while promoting students׳ confidence and competence. The flexible academic programme enabled students to access learning at any time and prioritise continuity of care experiences. Strategies are needed to better support students achieve a satisfactory work-life balance.

A cross-sectional study to determine utility of childbirth fear screening in maternity practice - An Australian perspective

BACKGROUND Low intensity anxiety in pregnancy is normal however high levels of fear affect between 20% and 25% of women, with around 10% suffering severe levels. Research from Scandinavian countries includes women with severe levels of fear, with little work undertaken in Australia. This paper explores predictors of fear and the relative benefits of screening women for childbirth fear at high or severe levels. METHOD A secondary analysis of data collected for the BELIEF study was conducted to determine differences for demographic, psycho-social and obstetric factors in women with severe fear (W-DEQ ≥85, n=68) compared to women with less or no fear (n=1318). Women with severe fear (W-DEQ ≥85, n=68) were also compared to those with high fear scores (W-DEQ ≥66-84, n=265). Logistic regression modelling was used to ascertain if screening for high or severe levels of fear is most optimal. RESULTS 1386 women completed the W-DEQ. There were no differences on demographic variables between women with severe or high fear. Depression symptoms, decisional conflict and low self-efficacy predicted high and severe fear levels. Nulliparity was a predictor of high fear. A previous operative birth and having an unsupportive partner were predictors of high fear in multiparous women. CONCLUSION Psychosocial factors were associated with both high and severe fear levels. Screening for severe fear may detect women with pre-existing mental health problems that are exacerbated by fear of birth. Australian women with high childbirth fear levels (W-DEQ ≥66) should be identified and provided appropriate support.

Commencing Undergraduate Midwifery Students' Beliefs About Birth and the Role of the Midwife

BACKGROUND: A shift has occurred in the last decade toward preregistration undergraduate Bachelor of Midwifery programs in Australia. This has led to an increase in the numbers of student midwives from diverse backgrounds with limited experience of university and socialization into hospital systems. AIM: This study aimed to explore commencing midwifery students’ beliefs about birth and expectations of the role of the midwife. METHOD: A qualitative descriptive approach was used. All 115 commencing first-year midwifery students enrolled in the first week of an undergraduate Bachelor of Midwifery program were invited and completed a self-administered survey. The survey used open-ended questions to elicit student beliefs about birth and the role of the midwife. Latent content analysis was used to analyze the data set. FINDINGS: Midwifery students’ beliefs were captured within the four themes: birth as “a miracle,” “a woman’s journey,” “a transformative event,” and “a natural process.” Students articulated the role of the midwife as one of support, education, advocacy, and partnership. Student beliefs and expectations were aligned with the emergent philosophy of the normality of birth and woman-centered care within the Australian maternity care context. CONCLUSION: Greater understanding is essential to designing quality midwifery education programs that are responsive to the needs of commencing student midwives. Supporting midwifery students’ successful transition into, and early engagement with the midwifery profession, may have long-term benefits in terms of retention and successful completion of their program. In addition, ensuring professional socialization occurs early is likely to develop graduates who are well prepared to work across their full scope and are willing to participate in the reform of maternity services in Australia.

The emotional and professional wellbeing of Australian midwives: A comparison between those providing continuity of midwifery care and those not providing continuity

BACKGROUND Continuity of midwifery care contributes to significant positive outcomes for women and babies. There is a perception that providing continuity of care may negatively impact on the wellbeing and professional lives of midwives. AIM To compare the emotional and professional wellbeing as well as satisfaction with time off and work-life balance of midwives providing continuity of care with midwives not providing continuity. METHOD Online survey. Measures included; Copenhagen Burnout Inventory (CBI); Depression, Anxiety and Stress Scale-21; and Perceptions of Empowerment in Midwifery Scale (PEMS-Revised). The sample (n=862) was divided into two groups; midwives working in continuity (n=214) and those not working in continuity (n=648). Mann Whitney U tests were used to compare the groups. RESULTS The continuity group had significantly lower scores on each of the burnout subscales (CBI Personal p=.002; CBI Work p<.001; CBI Client p<.001) and Anxiety (p=.007) and Depression (p=.004) sub-scales. Midwives providing continuity reported significantly higher scores on the PEMs Autonomy/Empowerment subscale (p<.001) and the Skills and Resources subscale (p=.002). There was no difference between the groups in terms of satisfaction with time off and work-life balance. CONCLUSION Our results indicate that providing continuity of midwifery care is also beneficial for midwives. Conversely, midwives working in shift-based models providing fragmented care are at greater risk of psychological distress. Maternity service managers should feel confident that re-orientating care to align with the evidence is likely to improve workforce wellbeing and is a sustainable way forward.

A third of midwives who have experienced traumatic perinatal events have symptoms of post-traumatic stress disorder.

Commentary on : Sheen K, Spiby H, Slade P. Exposure to traumatic perinatal experiences and posttraumatic stress symptoms in midwives: prevalence and association with burnout. Int J Nurs Stud 2015;52:578–87.[OpenUrl][1][CrossRef][2][PubMed][3] There is increasing recognition that witnessing traumatic events, as well as caring for traumatised individuals, … [1]: {openurl}?query=rft.jtitle%253DInt%2BJ%2BNurs%2BStud%26rft.volume%253D52%26rft.spage%253D578%26rft_id%253Dinfo%253Adoi%252F10.1016%252Fj.ijnurstu.2014.11.006%26rft_id%253Dinfo%253Apmid%252F25561076%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/j.ijnurstu.2014.11.006&link_type=DOI [3]: /lookup/external-ref?access_num=25561076&link_type=MED&atom=%2Febnurs%2F19%2F2%2F44.atom

Reforming maternity services in Australia: Outcomes of a private practice midwifery service

BACKGROUND AND AIMS recent legislative changes in Australia have enabled eligible midwives to provide private primary maternity care with fee rebates through Medicare. This paper (1) discusses these changes affecting midwifery practice; (2) describes Australias first private midwifery service with visiting rights to hospital for labour and birth care since Medicare funding for midwives was introduced in 2010; and (3) compares outcomes with National Core Maternity Indicators. METHODS an audit of all client records (n=323) for the survey period from September 2012 to February 2014 was undertaken. Data were extracted and compared with the 10 perinatal indicators using Chi square statistics. FINDINGS this convenience sample of all-risk women was similar to the national birthing population for age and parity. Compared to national indicators, women were significantly more likely to have spontaneous commencement of labour (79.6% versus 54.8%) (χ(2)=79.88, p<.001), lower rates of induction (10.2% versus 26%) (χ(2)=79.88, p<.001), and not require pharmacological pain relief (54.8% versus 23.9%) (χ(2)=152.2, p<.001). The majority of women had a normal vaginal birth (70.3% versus 55.1%) (χ(2)=28.13, p<.001). The caesarean section rate (22% versus 32.3%) was significantly lower (χ(2)=15.64, p<.001) than the national rate. Average gestation of neonates was 39.3 weeks; average birth weight was 3525 gms, and fewer required transfer to the special care nursery (8.4% versus 15.3%) (χ(2)=11.89, p<.001). DISCUSSION this is the first report of maternal and neonatal outcomes for a private midwifery service in Australia since the introduction of access to Medicare for midwives. Maternal and newborn outcomes were statistically better than national rates. Routinely reporting and publishing clinical outcomes needs to become the norm for private maternity care. CONCLUSIONS this private midwifery caseload model has been instrumental in the ground-breaking change to primary maternity services that extends women׳s access to safe midwifery care in Australia. The potential impact of private practicing midwives to align maternity care with the best available evidence is significant.

An economic evaluation alongside a randomised controlled trial on psycho-education counselling intervention offered by midwives to address women's fear of childbirth in Australia

OBJECTIVE The rate of caesarean section continues to increase, and there is evidence that childbirth fear is a contributing factor. Insufficient evidence is available on the impact of reducing childbirth fear on health-related quality of life and health service use. We undertook an economic evaluation of a psycho-education counselling intervention offered by midwives to address womens fear of childbirth in Australia. METHODS Pregnant women (n = 339) with high childbirth fear were randomised to a midwife-led psycho-education intervention for childbirth fear or to usual care. This paper presents the economic evaluation of the intervention based on health-related quality of life and health service use from recruitment to six weeks postpartum (n = 184). RESULTS The changes in health-related quality of life after birth (EQ-5D-3L: 0.016 vs. 0.010, p = 0.833, for usual care and intervention) and total health care use cost (AUS