The influences on women who choose a publicly-funded homebirth in Australia

University of Technology, Sydney. Faculty of Health.In Australia, homebirth has not been a mainstream option for childbirth for many years due to political reasons, societal attitudes towards childbirth, and a lack of services Since the 1990s, publicly-funded homebirth services have developed as a result of a growing demand from women and midwives. These services are few in number, and often embedded within a midwifery group practice in a hospital setting. As a relatively new model of care, these services have had little formal research, and only a few evaluations. The purpose of this study was to explore the influences on women who chose a publicly-funded homebirth. The setting was a publicly-funded homebirth service in southern Sydney, New South Wales, Australia. A grounded theory methodology, using a feminist approach was used to collect and analyse the data. Data were collected though semi-structured interviews of 18 women, 5 midwives and 2 partners of the women. Six main categories emerged from the data. These described the influences women had when they chose to have a publicly-funded homebirth. These categories were feeling independent, strong and confident, doing it my way, protection from hospital related activities, having a safety net, selective listening and telling, and engaging support. The core category was having faith in normal. This category linked all the other categories and was an overriding attitude towards themselves as women and the process of childbirth. The basic social process was validating the decision to have a homebirth. This was a dynamic, changeable process and principally a strategy to lessen stress regarding their decision to have a homebirth by reinforcing already-held reasons (for example, their ‘low risk’ status, strength and ability to have a normal birth) and beliefs (for example, their faith in normal, natural processes). The findings establish that women have similar influences to other studies of women when choosing homebirth. However, the women in this study were reassured by the publicly-funded system’s ‘safety net’ and seamless links with the hospital system. The flexibility of the service to permit women to change their minds to give birth in hospital, and essentially choose their birthplace at any time during pregnancy or labour was also appreciated

Publicly-funded homebirth models in Australia

Background: Publicly-funded homebirth programs in Australia have been developed in the past decade mostly in isolation from each other and with limited published evaluations. There is also distinct lack of publicly available information about the development and characteristics of these programs. We instigated the National Publicly-funded Homebirth Consortium and conducted a preliminary survey of publicly-funded homebirth providers. Aim: To outline the development of publicly-funded homebirth models in Australia. Methods: Providers of publicly-funded homebirth programs in Australia were surveyed using an on-line survey in December 2010. Questions were about their development, use of policy and general operational issues. A descriptive analysis of the quantitative data and content analysis of the qualitative data was undertaken. Findings: In total, 12 programs were identified and 10 contributed data to this paper. The service providers reported extensive multidisciplinary consultation and careful planning during development. There was a lack of consistency in data collection throughout the publicly-funded homebirth programs due to different databases, definitions and the use of different guidelines. Discussion: Publicly-funded homebirth services followed different routes during their development, but essentially had safety and collaboration with stakeholders, including women and obstetricians, as central to their process. Conclusion: The National Publicly-funded Homebirth Consortium has facilitated a sharing of resources, processes of development and a linkage of homebirth services around the country. This analysis has provided information to assist future planning and developments in models of midwifery care. It is important that births of women booked to these programs are clearly identified when their data is incorporated into existing perinatal datasets. © 2011 Australian College of Midwives

Multiparous women's confidence to have a publicly-funded homebirth: A qualitative study

Background: Hospital birth is commonly thought to be a safer option than homebirth, despite many studies showing similar rates of safety for low risk mothers and babies when cared for by qualified midwives with systems of back-up in place. Recently in Australia, demand has led to the introduction of a small number of publicly-funded homebirth programs. Women's confidence in having a homebirth through a publicly-funded homebirth program in Australia has not yet been explored. Aim: The aim of the study was to explore the reasons why multiparous women feel confident to have a homebirth within a publicly-funded model of care in Australia. Methods: Ten multiparous English-speaking women who chose to have a homebirth with the St George Hospital Homebirth Program were interviewed in the postnatal period using semi-structured, open-ended questions. Interviews were transcribed, then a thematic analysis was undertaken. Results: Women, having already experienced a normal birth, demonstrated a strong confidence in their ability to give birth at home and described a confidence in their bodies, their midwives, and the health system. Women weighed up the risks of homebirth through information they gathered and integration with their previous experience of birth, their family support and self-confidence. Discussion: Women choosing publicly-funded homebirth display strong confidence in both themselves to give birth at home, and their belief in the health system's ability to cope with any complications that may arise. Implications for practice: Many women may benefit from access to publicly-funded homebirth models of care. This should be further investigated. © 2010 Australian College of Midwives

Examining the content validity of the Birthing Unit Design Spatial Evaluation Tool (BUDSET) within a woman-centred framework.

Introduction: The environment for birth influences women in labor. Optimal birthing environments have the potential to facilitate normal labor and birth. The measurement of optimal birth units is currently not possible because there are no tools. An audit tool, the Birth Unit Design Spatial Evaluation Tool (BUDSET), was developed to assess the optimality of birthing environments. The BUDSET is based on 4 domains (fear cascade, facility, aesthetics, support), each comprising design principles that are further differentiated into specific assessable design items. In the process of developing measurement tools, content validity must be established. The aim of this study was to establish the content validity of the BUDSET from the perspective of women and midwives. Methods: This was a mixed-methods study with a survey assessing agreement with BUDSET items and in-depth interviews. Survey results were analyzed using an item-level content validity index and a survey-level validity index. Interview data were analyzed using a directed content analysis approach. The study was conducted in 2 locations¿a major maternity hospital and a midwifery research center, both in Australia. Study participants were 10 women and 2 midwifery academics. Results: The survey revealed that content-related validity varied according to the BUDSET domain, with the domains of facility and support established as content valid by most participants. The domains of the fear cascade and aesthetic were less strong, particularly among pregnant women. Interview data analysis provided content validity evidence of both the fear cascade and aesthetic domains. A further 4 subthemes of fear cascade also were identified: foreign space, medical-hospital-emergency, being sterile/clinical, and protecting the woman from the environment. Content validity evidence for facility and support domains also was established. Discussion: This study has established that the BUDSET is content valid for assessing the optima ity of birthing environments. Some further refinement of the tool is now possible

Maternal mortality in Australia: Learning from maternal cardiac arrest

Cardiac arrest in pregnancy is fortunately a rare event that few midwives will see during their career. The increase in maternal age, the Body Mass Index, cesarean sections, multiple pregnancies, and comorbidities over recent years have increased the probability of cardiac arrest. The early warning signs of impending maternal cardiac arrest are either absent or go unrecognized. Maternal mortality reviews highlight the deficiencies that maternity care providers have in managing cardiac arrest in pregnancy. The aim of this article is to address the knowledge deficiencies of health professionals by reviewing the physiological changes in pregnant women that complicate the management of cardiopulmonary resuscitation, using a case scenario. There are key differences in the management of pregnant women, when compared to standard adult resuscitation. The outcome is dependent on the speed of the response and the consideration of a number of crucial pregnancy-specific interventions. Staff members need to be adequately trained in order to deal with maternal cardiac arrest and have access to training packages and in-service education programs. As cardiac arrest in pregnancy is a rare event, emergency drill simulations are an important component of ongoing education. © 2011 Blackwell Publishing Asia Pty Ltd.

Publicly funded homebirth in australia: A review of maternal and neonatal outcomes over 6 years

Objective: To report maternal and neonatal outcomes for Australian women planning a publicly funded homebirth from 2005 to 2010. Design, setting and subjects: Retrospective analysis of data on women who planned a homebirth and on their babies. Data for 2005-2010 (or from the commencement of a program to 2010) were requested from the 12 publicly funded homebirth programs in place at the time. Main outcome measures: Maternal outcomes (mortality; place and mode of birth; perineal trauma; type of management of the third stage of labour; postpartum haemorrhage; transfer to hospital); and neonatal outcomes (early mortality; Apgar score at 5 minutes; birthweight; breastfeeding initially and at 6 weeks; significant morbidity; transfer to hospital; admission to a special care nursery). Results: Nine publicly funded homebirth programs in Australia provided data accounting for 97% of births in these programs during the period studied. Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%. Conclusion: This study provides the first national evaluation of a significant proportion of women choosing publicly funded homebirth in Australia; however, the sample size does not have sufficient power to draw a conclusion about safety. More research is warranted into the safety of alternative places of birth within Australia

Violence toward nurses, the work environment, and patient outcomes

Purpose: To relate nurses' self-rated perceptions of violence (emotional abuse, threat, or actual violence) on medical-surgical units to the nursing working environment and to patient outcomes.Design: Cross-sectional collection of data by surveys and primary data collection for 1-week periods on 94 nursing wards in 21 hospitals in two states of Australia.Methods: Nursing Work Index-Revised (NWI-R); Environmental Complexity Scale (ECS) PRN-80 (a measure of patient acuity); and a nursing survey with three questions on workplace violence; combined with primary data collection for staffing, skill mix, and patient outcomes (falls, medication errors).Findings: About one third of nurses participating (N=2,487, 80.3% response rate) perceived emotional abuse during the last five shifts worked. Reports of threats (14%) or actual violence (20%) were lower, but there was great variation among nursing units with some unit rates as high as 65%. Reported violence was associated with increased ward instability (lack of leadership; difficult MD and RN relationships). Violence was associated with unit operations: unanticipated changes in patient mix; proportion of patients awaiting placement; the discrepancy between nursing resources required from acuity measurement and those supplied; more tasks delayed; and increases in medication errors. Higher skill mix (percentage of registered nurses) and percentage of nurses with a bachelor of science in nursing degrees were associated with fewer reported perceptions of violence at the ward level. Intent to leave the present position was associated with perceptions of emotional violence but not with threat or actual assault.Conclusions: Violence is a fact of working life for nurses. Perceptions of violence were related to adverse patient outcomes through unstable or negative qualities of the working environment. Perceptions of violence affect job satisfaction.Clinical Relevance: In order to manage effectively the delivery of nursing care in hospitals, it is essential to understand the complexity of the nursing work environment, including the relationship of violence to patient outcomes. © 2009 Sigma Theta Tau International

The implications of staff 'churn' for nurse managers, staff, and patients

▶ In this article, the term "churn" is used not only because of the degree of change to staffing, but also because some of the reasons for staff movement are not classified as voluntary turnover. ▶ The difficulties for the nurse managing a unit with the degree of "churn" should not be under-estimated. ▶ Changes to skill mix and the proportions of full-time, agency, and temporary staff present challenges in providing clinical leadership, scheduling staff, performance management, and supervision. ▶ Perhaps more importantly, it is likely that there is an impact on the continuity of care provided in the absence of continuity of staffing. ▶ A greater understanding of the human and financial costs and consequences, and a willingness to change established practices at the institutional and ward level, are needed

Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: A systematic review

Aim. The aim of this study was to review non-clinical interventions that increase the uptake and/or the success rates of vaginal birth after caesarean section. Background. Increases in rates of caesarean section are largely due to repeat caesarean section in a subsequent pregnancy. Concerns about vaginal birth after caesarean section have centred on the risk of uterine rupture. Nonetheless, efforts to increase the vaginal birth rate in these women have been made. This study reviews these in relation to non-clinical interventions. Data sources. Literature was searched up until December 2008 from five databases and a number of relevant professional websites. Review methods. A systematic review of quantitative studies that evaluated a non-clinical intervention for increasing the uptake and/or the success of vaginal birth after caesarean section was undertaken. Only study designs that involved a comparison group were included. Further exclusions were imposed for quality using the Critical Skills Appraisal Programme. Results. National guidelines influence vaginal birth after caesarean section rates, but a greater effect is seen when institutions develop local guidelines, adopt a conservative approach to caesarean section, use opinion leaders, give individualized information to women, and give feedback to obstetricians about mode of birth rates. Individual clinician characteristics may impact on the number of women choosing and succeeding in vaginal birth after caesarean section. There is inconsistent evidence that having private health insurance may be a barrier to the uptake and success of vaginal birth after caesarean section. Conclusion. Non-clinical factors can have a significant impact on vaginal birth after caesarean section uptake and success. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd