BACKGROUND: Evidence indicates that retraumatization has a detrimental effect for those women who are accessing perinatal services. One in five women worldwide has a history of childhood adversity. Between 18% and 34% of women experience trauma, which is a well-known risk factor for the onset of chronic mental health disorders. There is a lack of evidence on women\'s experiences on retraumatization in perinatal care settings and how to prevent retraumatization from occurring. The purpose of this study was to conduct an integrative review on women experiences of retraumatization to determine preventive measures within perinatal services.
METHODS: This integrative review followed Whittemore and Knafl\'s 5-stage framework as it allows for the inclusion and integration of diverse research methodologies into an overall synthesis of the evidence. A systematic search of 5 databases was conducted (Web of Science, MEDLINE, CINAHL, ASSIA, and PsychINFO) with no date, language, or geographical limits set due to the paucity of research published in this subject area. This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
RESULTS: Fifteen studies met the inclusion criteria and were included in the thematic synthesis. The review identified that participants across the studies had a history of child sexual abuse, sexual abuse, and rape. Three main themes plus subthemes were identified: (1) activating (subthemes: positions in labor, intimate procedures, communications with health care professionals, loss of control); (2) outcomes (subtheme: emotional responses); and (3) interventions reducing or preventing retraumatization (subthemes: role of the health care professional, screening for abuse and history of trauma).
CONCLUSIONS: Our findings demonstrate that women are experiencing retraumatization in perinatal services, and there is evidence of formalized approaches being applied in clinical settings to prevent retraumatization from occurring. This study is the first to examine the factors that contribute to retraumatization in perinatal services and make recommendations to reduce the harmful practices in place in perinatal care settings.

OBJECTIVE: This study aimed to explore the \'real time\' expectations, experiences and needs of men who attend maternity services to inform the development of strategies to enhance men\'s inclusion.
METHODS: A qualitative descriptive design was adopted for the study. Semi-structured face-to-face or telephone interviews were conducted with 48 men attending the Royal Brisbane and Women\'s Hospital before and after their partner gave birth. Data were coded and analysed thematically.
RESULTS: Most respondents identified their role as a support person rather than a direct beneficiary of maternity services. They expressed the view that if their partner and baby\'s needs were met, their needs were met. Factors that contributed to a positive experience included the responsiveness of staff and meeting information needs. Factors promoting feelings of inclusion were being directly addressed by staff, having the opportunity to ask questions, and performing practical tasks associated with the birth.
CONCLUSIONS: Adopting an inclusive communication style promotes men\'s feelings of inclusion in maternity services. However, the participants\' tendency to conflate their needs with those of their partner suggests the ongoing salience of traditional gender role beliefs, which view childbirth primarily as the domain of women.

OBJECTIVE: Families living in rural communities need to relocate, be transferred or travel long distances to access specialist maternal and neonatal care, leading to isolation from their support networks.
BACKGROUND: High-risk maternal and neonatal complexities in rural maternity units results in more transfers and retrievals to metropolitan services. There is limited understanding of the physical and psychological impacts for women and their families when they are transferred or displaced from their rural communities during pregnancy.
OBJECTIVE: To investigate the lived experience of relocation for specialist pregnancy, birthing, postnatal and neonatal care on women and families.
METHODS: Women (n=5) and partners (n=4) from rural South Australia, participated in semi-structured interviews on their experiences of transfer from local maternity providers. Couples interviewed together, interactions were recorded, transcribed verbatim and thematically analysed to identify overarching and sub-themes.
RESULTS: The overarching theme was \'mismatched expectations\', with three identified sub-themes: \'communication\', \'compassion\' and \'safety\'. Discrepancies between expectations and realities during relocation left participants feeling isolated, alone and needing to self-advocate during this vulnerable period. Despite receiving specialist care, women and partners encountered unique hardships when separated from their rural community. Their social needs were poorly understood and seldom addressed in specialist units, resulting in poor experiences.
CONCLUSIONS: Consideration regarding the impact of attending specialist maternity services for women and partners from rural areas is required. The \'one size fits all\' approach for maternity care is unrealistic and research is needed to improve the experiences for those uprooted from rural communities for higher levels of care.

This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project\'s operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent.

OBJECTIVE: Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement.
METHODS: A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses.
RESULTS: Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth.
CONCLUSIONS: Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced.

UNASSIGNED: Pregnant women have preferences about how they intend to manage labour pain. Unmet intentions can result in negative emotions and/or birth experiences.
UNASSIGNED: To examine the antenatal level of intention for intrapartum pain relief and the factors that might predict this intention.
UNASSIGNED: A cross-sectional online survey-based study.
UNASSIGNED: 414 healthy pregnant women in the Netherlands, predominantly receiving antenatal care from the community-based midwife who were recruited via maternity healthcare professionals and social media platforms.
UNASSIGNED: The attitude towards intrapartum pain relief was measured with the Labour Pain Relief Attitude Questionnaire for pregnant women. Personality traits with the HEXACO-60 questionnaire, general psychological health with the Mental Health Inventory-5 and labour and birth anxiety with the Tilburg Pregnancy Distress Scale. Multiple linear regression was performed with the intention for pain relief as the dependant variable.
UNASSIGNED: The obstetrician as birth companion (p<.001), the perception that because of the impact of pregnancy on the woman\'s body, using pain relief during labour is self-evident (p<.001), feeling convinced that pain relief contributes to self-confidence during labour (p=.023), and fear of the forthcoming birth (p=.003) predicted women were more likely to use pain relief. The midwife as birth companion (p=.047) and considering the partner in requesting pain relief (p=.045) predicted women were less likely to use pain relief.
UNASSIGNED: Understanding the reasons predicting women\'s intention of pain management during labour, provides insight in low-risk women\'s supportive needs prior to labour and are worth paying attention to during the antenatal period.

Strategies to reduce over-representation of Indigenous children in out-of-home care must start in pregnancy given Indigenous babies are 6 % of infants (<1 year), yet 43 % of infants in out-of-home care.
To determine if an Indigenous-led, multi-agency, partnership redesign of maternity services decreases the likelihood of babies being removed at birth.
Women carrying an Indigenous baby/babies who gave birth at the Mater Mothers\' Public Hospital, Brisbane (2013-2019).
A prospective, non-randomised, intervention trial evaluated a multi-agency service redesign. Women pregnant with an Indigenous baby birthing at a tertiary hospital were offered standard care or Birthing in Our Community (BiOC) service. We compared likelihood of babies being removed by Child Protection Services (CPS) at birth by model of care. Inverse probability of treatment propensity score weighting controlled baseline confounders and calculated treatment effect. Standardized differences were calculated to assess balance of risk factors for each copy of multiple imputation. Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.
In 2013-2019, 1988 women gave birth to 2044 Indigenous babies, with 40 women having babies removed at birth (9 BiOC, 31 standard care). Adjusted odds of baby removal were significantly lower for mothers in BiOC compared to standard care (AOR 0.37, 95 % CI 0.16, 0.84). In total, 2.0 % of Indigenous babies were removed by CPS; eight times higher than non-Indigenous babies at the same hospital (0.25 %).
BiOC reduced removals of newborn Indigenous babies likely disrupting generational cycles of CPS contact, trauma, and maltreatment, and contributing to short and long-term health and wellbeing benefits for mothers and babies.

OBJECTIVE: To evaluate midwives\' level of stress and burnout during the COVID-19 Omicron phase in Italy. Secondary aims were to explore the impact of the pandemic on midwives\' personal dimensions and professional activities and potential supporting strategies.
METHODS: A mixed-methods study was undertaken from July to December 2022.
METHODS: Data were collected using a national online observational survey. Descriptive and inferential analyses were performed to evaluate stress, burnout and the impact of the pandemic on personal and professional dimensions. A deductive qualitative approach was used to analyse open-ended responses, that were merged with quantitative data following a convergent mixed-methods approach.
RESULTS: A total of 1944 midwives participated in the survey. The stress summary score mean was 10.34, and 562 midwives (28.91%) experienced burnout. The intention to reduce working hours was reported by 202 midwives (10.39%), with 60.40% (n = 122) of them experiencing burnout. The intention to leave clinical practice within the following 2 years was reported by 239 (12.29%), with 68.20% (n = 163) of them experiencing burnout. All the personal dimensions and professional activities considered were defined by more than half of midwives as being impacted \'Moderately\' or \'To a great extent\' by pandemic. Stress and burnout frequencies increased when the midwives\' perception of the pandemic effects was higher. Potential supporting strategies described by midwives as the most important in increasing their ability to cope with the pandemic were \'Women\'s awareness of the midwives\' role\' (n = 1072; 55.14%) and \'Family and friends\' emotional support\' (n = 746; 38.38%).
CONCLUSIONS: Our findings suggested strategies to support a positive and safe working environment for midwives during a pandemic emergency, with potential transferability to similar contexts when human resources are lacking. It is recommended that maternity services provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout.
CONCLUSIONS: Studies conducted during the first COVID-19 pandemic wave showed an increased level of stress, anxiety, burnout, post-traumatic stress disorder and depression experienced by healthcare professionals; moreover, midwives experienced drastic changes in care pathways and policies with struggles identified when providing high-quality woman-centred care following pandemic restrictions. Although it is recommended, there is lack of knowledge about long-term psychological effects of COVID-19 for midwives. Our study highlights that during the Omicron wave midwives experienced a high level of stress and burnout with an impact on individual dimensions and professional activities. Their stress and burnout were influenced by several factors, including restrictions in place, lack of organizational acknowledgement, work overload and need for extra childcare cover. Maternity services should provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. Recommendations on how to facilitate this are suggested.
UNASSIGNED: During the writing process, we referred to \'The Strengthening the Reporting of Observational Studies Epidemiology Statement\', the guidelines for reporting observational studies from the Equator network.
UNASSIGNED: No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Work overload conditions negatively impacted on the quality of maternity services. Improving organizational aspects, reducing working hours, promoting family and friends\' emotional support and improving women\'s awareness of midwife\'s role were the main strategies reported by midwives. These suggestions for ensuring a positive and safe working environment for midwives during a pandemic emergency could potentially be applied to similar situations where human resources are lacking.

OBJECTIVE: Establishment of Birthing on Country services owned and governed by Aboriginal and Torres Strait Islander Community Controlled Health Services has been slow.
BACKGROUND: Birthing on Country services have demonstrated health and cost benefits and require redesign of maternity care. During the Building On Our Strengths feasibility study, use of endorsed midwives and licensing of birth centres has proven difficult.
OBJECTIVE: What prevents Community Controlled Health Services from implementing Birthing on Country services in Queensland and New South Wales?
METHODS: Participatory action research identified implementation barriers. We conducted iterative document analysis of instruments to inform government lobbying through synthesis of policy, economic, social, technological, legal, and environmental factors.
RESULTS: Through cycles of participatory action research, we analysed 17 documents: 1) policy barriers prevent Community Controlled Health Services from employing endorsed midwives to provide intrapartum care in public hospitals; 2) economic barriers include lack of sustainable funding stream and inadequate Medicare-billing for endorsed midwives; and 3) legal barriers require a medical practitioner in a birth centre. While social barriers (e.g., colonisation, medicalisation) underpin regulations, these were beyond the scope; technological and environmental barriers were not identified.
CONCLUSIONS: Findings are consistent with the literature on barriers to midwifery practice. Recommendations include a national audit of barriers to Birthing on Country services including healthcare practice insurance, and development of a funding stream. Additionally, private maternity facility regulation must align with evidence on safe birth centre operation.
CONCLUSIONS: Government can address barriers to scale-up of Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services.

BACKGROUND: The COVID-19 pandemic led to significant changes in maternity service delivery in England, including: antenatal appointments being cancelled or held by phone; women having to attend antenatal scans alone; partners not being allowed to accompany women during labor; visitor restrictions on postnatal wards; and limited postnatal support.
METHODS: We conducted semi-structured interviews with 46 women aged 18-45 who had low-risk pregnancies and gave birth to their babies using NHS services in England between 1st March 2020 and 1st March 2021.
RESULTS: Our thematic analysis of interview data generated key themes: profound negative impacts of birth partners not being allowed to accompany women (including on emotional wellbeing, birth preferences and care-seeking choices); deep frustration about policy variation between trusts and inconsistent implementation of guidance; women being more concerned about the risk of giving birth alone than of COVID-19 infection; and women turning towards private care or delaying seeking NHS care so that they could have the birth experience they desired. The latter two results are, to the best of our knowledge, unique to this paper.
CONCLUSIONS: Our participants reported significant negative affects to their emotional and physical wellbeing because of maternity service restrictions. Going forward, efforts are required by policymakers and health service providers to re-establish trust in NHS maternity care and ensure capacity to provide for potential shifts in birthplace preferences. Health systems strengthening efforts should prioritise protecting the rights of women to access high quality, person-centred care in the event of future health emergencies that strain NHS capacity.