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Professor Maralyn Foureur

Biography

Maralyn is currently Professor of Midwifery  in the Centre for Midwifery, Child and Family Health at UTS and Adjunct Professor of Midwifery at Victoria University of Wellington, New Zealand and the University of Southern Denmark. She has led research into the development and implementation of innovative models of midwifery care and the development of midwifery practice and education. Her other research includes a major focus on how the Birth Unit Design impacts on women and staff stress, communication, and ultimately birth outcomes.

She holds 3 NHMRC (CI and AI) and 1 ARC grant as a CI and supervises Doctoral (PhD and Professional Doctorate), Masters and Honours students studying aspects of improving maternity services including: a cohort study of pregnant women with Group B Streptococcus Infection; A case study of antenatal depression screening; a video-ethnographic study of the impact of Birth Unit Design on the behaviour and practices of midwives; the impact of Birth Unit Design on the experiences of supporters in childbirth;a case study of  midwifery students’ experiences of continuity of care models of education; a mixed methods study to evaluate the NSW Fetal welfare and Obstetric and Neonatal Training (FONT) program; a mixed methods study of the culture of the maternity unit; a discourse analysis of the concept of time and induction of labour; a critique of the Baby Friendly Hospital Initiative (BFHI). 

Maralyn co-leads the consortium called Birth After Caesarean Interventions (BACI) which is undertaking research to promote normal birth and increase the rate of vaginal birth after caesarean section. She undertakes a range of projects within the clinical setting of the Central Coast and Northern Sydney LHNs which includes establishing and evaluating an innovative model of care for obese pregnant women; establishing and evaluating models of midwifery continuity of care. She is also involved in teaching midwifery students and teaches in the Bachelor of Midwifery, Graduate Diploma of Midwifery and Master of Midwifery programs.

Maralyn also holds a Bachelor of Arts degree majoring in Psychology and Sociology (Flinders University, S. Aust.) and a Graduate Diploma in Clinical Epidemiology and Biostatistics (University of Newcastle, NSW). She is a Fellow of the Australian College of Midwives (ACM).

Maralyn is a member of the editorial panel of Women and Birth and regularly reviews articles for a number of other journals including Rural and Remote Health, BMC Pregnancy and Childbirth, Midwifery: An International Journal; Australian and New Zealand Journal of Obstetrics and Gynaecology

1994-1995 Lecturer: Faculty of Nursing & Midwifery, University of Newcastle, NSW
1996-1998 Senior Lecturer: Grad School Nursing, Midwifery & Health (GSNMH), Victoria University of Wellington (VUW), NZ
1998-2005 Clinical Professor Midwifery, GSNMH, VUW & Wellington Womens Hospital
2006 Professor of Midwifery GSNMH VUW
2006 (August) Assoc Professor Research Faculty of Nursing Midwifery and Health UTS
2006 Adjunct Professor of Midwifery GSNMH VUW Wellington New Zealand
2007 Clinical Professor of Midwifery Faculty of Nursing Midwifery and Health UTS and Northern Sydney Central Coast Area Health Service

Professional

Fellow - Australian College of Midwives
Member - Australian College of Midwives NSW
Member - New Zealand College of Midwives
Member Perinatal Society of Australia and New Zealand
Member Editorial Board: Women & Birth
Member Editorial Board: Journal of the New Zealand College of Midwives
Member editorial panel for MORE EBN, nursing +Best Evidence for Nursing Care, and Evidence-Based Nursing

Image of Maralyn Foureur
Professor, Faculty of Health
Member, Centre for Midwifery, Child and Family Health (CMCFH)
Course Coordinator, Faculty of Health
Core Member, Health Services and Practice Research Strength
BA, Epidemiology and Biostatistics, Doctor of Philosophy
Fellow, Australian College of Midwives
Member, Perinatal Society of Australia and New Zealand
 
Phone
+61 2 9514 4914
Room
CB10.07.252

Research Interests

Birth environment
Strategies for keeping birth normal
Physiology of normal childbirth
History of midwifery

Additional research interests
Impact of internal and external birth environment on woman and infant health
Prenatal and perinatal influences on child and adult health

Transdisciplinary models of education, research and clinical practice

  • Mixed Methods Research
  • Qualitative, interpretive designs

Can supervise: Yes

Registered at Level 1

Research areas
Action Research
Case Study
Critical Research Approaches
Delphi Technique
Ethnography
Feminist Research Narrative
Discourse or Historical Analysis
Phenomenology
Randomised Controlled Trials
Survey Methods

Midwifery - undergraduate and postgraduate
Research in midwifery, nursing and health services - postgraduate

Books

Foureur, M., Fahy, K. & Hastie, C. 2008, Birth Territory and Midwifery Guardianship, 1, Butterworth Heinemann Elsevier, Edinburgh, UK.
Midwives and other healthcare providers are grappling with the issue of rising intervention rates in childbirth and trying to identify ways to reverse the trend. It is increasingly accepted that intervention in childbirth has long-term consequences for women and their children. Birth Territory provides practical, evidence-based ideas for restructuring the birth territory to facilitate normal birth.
Fisher, K., Foureur, M. & Hawley, J. 2004, Maternity Services and Gynaecology Report 2003, Capital and Coast DHB, Wellington, New Zealand.
Analysis of the maternity service and gynaecology service processes and outcomes of a large regional maternity and womens health service in wellington, New Zealand. Recommendations for policy and practice made. Co-authored with Keith Fisher and Jackie Hawley
Fisher, K., Foureur, M. & Hawley, J. 2003, Maternity Report 1997-2002, Capital and Coast DHB, Wellington, New Zealand.
Analysis of the maternity outcomes database of a large regional maternity hospital in New Zealand with recommendations for practice change and new policy directions. Co-authored with Keith Fisher and Jackie Hawley

Chapters

Fahy, K., Parrat, J. & Foureur, M. 2011, 'Birth Territory: A Theory for Midwifery Practice' in Bryar, R. & Sinclair, M. (eds), Theory for Midwifery Practice, Second Edition, Palgrave MacMillan, Oxford, UK, pp. 215-240.
This new edition of a highly regarded classic midwifery text encourages critical thinking about the art and science of midwifery. Promoting the idea that thinking directly affects practice, it offers a clear explanation of the concepts, theories and models that shape effective evidence-informed care for women.
Lepori, B., Foureur, M. & Hastie, C. 2008, 'Mindbodyspirit Architecture: Creating birth space' in Fahy, K., Foureur, M. & Hastie, C. (eds), Birth Territory and Midwifery Guardianship, Elsevier, Oxford, UK, pp. 95-112.
Co-authored with Lepori, B and Hastie C. Examines the research evidence for the impact of the physical and emotional environment on the physiology of women in labour and birth. Proposes new principles for the design of birth spaces and sets a new research agenda.
Foureur, M. 2008, 'Creating Birth Space to Enable Undisturbed Birth' in Fahy, K., Foureur, M. & Hastie, C. (eds), Birth Territory and Midwifery Guardianship, Elsevier, Oxford, UK, pp. 57-78.
Foureur, M. & Sandall, J. 2008, 'The challenges of evaluating midwifery continuity of care' in Homer, Brodie & Leap (eds), Midwifery Continuity of Care: A practical guide, Churchill Livingstone Elsevier, Sydney, Australa, pp. 165-180.
In this chaprer) we describe some of the challenges associated with evaluating midwifery continuity of care. The notion of 'midwifery care as a complex intervention' is explored as this informs (he way it is evaluated. Midwifery models of care are complex as they consist of a package ofinrerventions. In evaluations we have often tried to reduce the cornplexity, which may actually leave out the things that arc most important. Murray Enkin, one of the original editors of Effective Care in Pregnancy and Childbirth (Chalmers et al. 1989), highlighted this understanding by saying "TI,e things that count cannot be counted'. This was a version of a famous quotation by Alben Einstein: 'Everything that can be counted does not necessarily count; and, everything that counts) cannot necessarily be counted'. 'lhis chapter deals with these issues and the importance of maintaining the complexity in evaluations by using a framework developed by the Medical Research Council of the United Kingdom as a way of thinking through and planning an evaluation. 'This chapter also includes a briefcritique of the evidence around midwifery continuity of care presented in Chapter 2.
Wood, P.J. & Foureur, M. 2007, 'A clean front passage: dirt, douches and disinfectants at St Helens Hospital, Wellington, New Zealand, 1907-1922' in Kirkham, M. (ed), Exploring the dirty side of women's health, Routledge, Great Britain, pp. 30-44.
This chapter was an invited publication in an international, refereed book. It is based on historical research using the archives of the St Helens Hospital Wellington 1907-1922. It is one of several publications and presentations arising from the archival database which we set up in 2000. This chapter explores the relationship between puerpural sepsis at the beginning of the 20th century and notions of dirt carried within the bodies of childbearing women. St Helens Hospitals were renowned for their cleanliness and attention to aspepsis. They had the lowest rate of puerpural sepsis in New Zealand. This chapter contributes to my research platform which explores the impact of the birth environment on birth outcomes -from a number of perspectives.
Foureur, M. 2005, 'Next Steps: Public Health in Midwifery Practice' in O'Luanaigh, P. & Carlson, C. (eds), Midwifery and Public Health: Future Directions and New Opportunities, Elsevier, Churchill Livingstone, London, UK, pp. 221-237.
The preceding chapters have provided insights into how the health agenda of governments in many developed countries has changed . The past focus on preventative health care and individual education for appropriate lifestyle choices has been recognised as limited and largely ineffectual in addressing the poor health of certain population groups. Governments have now embraced a broader understanding of the complex interactions and contributi on to health outcomes of not only individual behaviour but also socio-economic inequalities. This has led to a new public health agenda that seeks to engage communities , in concert with a range of health providers including midwives, to improve the health status of those who are currently disadvantaged.
Foureur, M. & Wood, P. 2005, 'Exploring the Maternity Archive of the St Helens Hospital Wellington New Zealand' in Mortimer, B. & McGann, S. (eds), New Directions in the History of Nursing, Routledge, Oxford, pp. 1907-1922.
This chapter, is an international publication, provides further evidence of my research platform in exploring the contributions of the complex nature of the birth environment to birth outcomes - this time from an historical perspective based on the maternity archives of the first St Helen's Hospital in New Zealand. This was an invited chapter following the presentation of the research which it is based to the conference celebrating the launch of the UK centre for the History of Nursing in Edingburgh in 2000. The ongoing research on which this chapter is based discovered that the reportedly low maternal mortality rates attributed to midwifery practices at the St Helen's Hospitals were due to the almost total absence of puerpural spesi. Maternal mortality from other causes was however the same as in the rest of the country. This chapter also provides further evidence of the international standing, and of the collaborative nature of my research, this time with a nurse historian.
Foureur, M. & Hunter, M. 2005, 'The Place of Birth' in Pairman, Pincombe, Thorogood, Tracy & Livingstone, C. (eds), MIdwifery Preparation for Practice, Elsevier, London, UK, pp. 1-25.
This chapter provides further evidence of my research platform and international standing. The chapter continues to explore the complex nature of the birth environment. It focuses on the place of birth and how this contributes to birth outcomes. The chapter was invited to be submitted following a conference presentation of the research on which it is based at the 7th ICM (International Conference of Midwives) Asia Pacific Regional Conference in Honk Kong, 27-28 November 2003.where I was the keynote speaker. This chapter was published as one of two sample chapters in the book to coincide with the international Confederation of Midwives Congress in Brisbane in July 2005 and will be included in the book of the same name to be published in 2006.
Wood, P.J. & Foureur, M. 2005, 'Exploring the maternity archive of the St Helens Hospital, Wellington, New Zealand 1907-1922: an historian and a midwifer collaborate' in MOrtimer, B. & McGann, S. (eds), New Directions in the History of Nursing: International perspectives, Routledge, London, UK, pp. 179-193.
An analysis of the maternity archive of the first publicly funded maternity hospital in New Zealand which opened at the turn of the 20th century. This was a midwifery led hospital with one consultant medical practitioner. The hospital was renowned for its high standards of cleanliness. The analysis critiques the understanding that most maternal deaths at the time were due to puerpural sepsis. At this hospital puerpural sepsis was a rare event and maternal deaths were due to a range of other causes.

Conferences

Foureur, M. 2010, 'Changing the Birth Environment to Facilitate Optimal Birth Experiences for Women'.
This paper explored the current research understanding of the physiology of stress in childbirth and how this impacts outcomes in labour and birth for women and babies. It proposed innovative strategies for focussed attention on aspects of the birth environment that are amendable to change and how optimal birth environments could lead to reduced intervention in childbirth.
Foureur, M. 2010, 'Epigenetics and the Birth Environment'.
This keynote addressed presented new research understanding of the influence of the birth environment -from preconception, through conception, pregnancy, labour, birth and the early postnatal period, on the human epigenome
Foureur, M. 2010, 'How the Birth Environment impacts the Human Epigenome'.
Presented animal and human research findings that describe the impact of stressful birth environments on short term birth outcomes and long term health behaviours of infants - and in particular focussed on changes to the epigenome
Hoang, D.B., Lawrence, E., Ahmad, N.F., Balasubramanian, V., Homer, C., Foureur, M. & Leap, N. 2008, 'Assistive Care Loop with Electronic Maternity Records', 2008 10TH IEEE INTERNATIONAL CONFERENCE ON E-HEALTH NETWORKING, APPLICATIONS AND SERVICES, IEEE, pp. 118-123.
Davis, D.L., Homer, C.S., Foureur, M., Leap, N. & Forbes, I. 2008, 'Birthing units: Designing homely delivery spaces to promote natural birth'.
Foureur, M. 2007, 'Establishing the principles for creating positive birth space (part 1)'.
Foureur, M. 2007, 'Enacting the principles for creating positive birth space (part 2)'.
Foureur, M. 2007, 'Creating Positive Birth Space'.

Journal articles

Homer, C.S.E., Thornton, C., Scarf, V.L., Ellwood, D.A., Oats, J.J.N., Foureur, M.J., Sibbritt, D., McLachlan, H.L., Forster, D.A. & Dahlen, H.G. 2014, 'Birthplace in New South Wales, Australia: an analysis of perinatal outcomes using routinely collected data', BMC PREGNANCY AND CHILDBIRTH, vol. 14.
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Hammond, A., Foureur, M. & Homer, C.S.E. 2014, 'The hardware and software implications of hospital birth room design: A midwifery perspective', Midwifery, vol. 30, no. 7, pp. 825-830.
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Objective: to explore the impacts of physical and aesthetic design of hospital birth rooms on midwives. Background: the design of a workplace, including architecture, equipment, furnishings and aesthetics, can influence the experience and performance of staff. Some research has explored the effects of workplace design in health care environments but very little research has examined the impact of design on midwives working in hospital birth rooms. Methods: a video ethnographic study was undertaken and the labours of six women cared for by midwives were filmed. Filming took place in one birth centre and two labour wards within two Australian hospitals. Subsequently, eight midwives participated in video-reflexive interviews whilst viewing the filmed labour of the woman for whom they provided care. Thematic analysis of the midwife interviews was undertaken. Findings: midwives were strongly affected by the design of the birth room. Four major themes were identified: finding a space amongst congestion and clutter; trying to work underwater; creating ambience in a clinical space and being equipped for flexible practice. Aesthetic features, room layout and the design of equipment and fixtures all impacted on the midwives and their practice in both birth centre and labour ward settings. Conclusion and implications for practice: the current design of many hospital birth rooms challenges the provision of effective midwifery practice. Changes to the design and aesthetics of the hospital birth room may engender safer, more comfortable and more effective midwifery practice. 2013 Elsevier Ltd.
Atchan, M., Davis, D. & Foureur, M. 2014, 'Applying a knowledge translation model to the uptake of the Baby Friendly Health Initiative in the Australian health care system.', Women Birth, vol. 27, no. 2, pp. 79-85.
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The Baby Friendly Hospital Initiative is a global, evidence-based, public health initiative. The evidence underpinning the Initiative supports practices promoting the initiation and maintenance of breastfeeding and encourages women's informed infant feeding decisions. In Australia, where the Initiative is known as the Baby Friendly Health Initiative (BFHI) the translation of evidence into practice has not been uniform, as demonstrated by a varying number of maternity facilities in each State and Territory currently accredited as 'baby friendly'. This variance has persisted regardless of BFHI implementation in Australia gaining 'in principle' support at a national and governmental level as well as inclusion in health policy in several states. There are many stakeholders that exert an influence on policy development and health care practices.
Hammond, A.D., Homer, C.E. & Foureur, M. 2014, 'Messages from Space: An Exploration of the Relationship between Hospital Birth Environments and Midwifery Practice.', HERD, vol. 7, no. 4, pp. 81-95.
To explore the relationship between the birth environment and the practice of midwifery using the theoretical approach of critical realism.
Davis Harte, J., Leap, N., Fenwick, J., Homer, C.S.E. & Foureur, M. 2014, 'Methodological insights from a study using video-ethnography to conduct interdisciplinary research in the study of birth unit design', International Journal of Multiple Research Approaches, vol. 8, no. 1, pp. 36-48.
Little is known about how the physical design of a birthing unit can influence the experiences of labour and birth for women, their supporters and midwives. We proposed that an interdisciplinary approach (disciplines of midwifery, architecture, design, communication and public health) was likely to be the most effective way to better understand the complexities and interactions of design, behaviour, communication and experiences. In this methodological paper we aim to provide a roadmap that other researchers may find helpful when considering the use of video as a data collection technique, especially in the study of the powerful and intimate setting of childbirth. The paper also outlines our process for engaging both researchers and participants in reviewing video footage with the aim to contribute multiple perspectives to the analysis process.
Maude, R., Skinner, J.P. & Foureur, M. 2014, 'Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women', BMC Pregnancy and Childbirth, vol. 14, no. 184, pp. 1-13.
Homer, C.S.E., Thornton, C., Scarf, V.L., Ellwood, D.A., Oats, J.J.N., Foureur, M.J., Sibbritt, D., McLachlan, H.L., Forster, D.A. & Dahlen, H.G. 2014, 'Birthplace in New South Wales, Australia: An analysis of perinatal outcomes using routinely collected data', BMC Pregnancy and Childbirth, vol. 14, no. 1.
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Background: The outcomes for women who give birth in hospital compared with at home are the subject of ongoing debate. We aimed to determine whether a retrospective linked data study using routinely collected data was a viable means to compare perinatal and maternal outcomes and interventions in labour by planned place of birth at the onset of labour in one Australian state.Methods: A population-based cohort study was undertaken using routinely collected linked data from the New South Wales Perinatal Data Collection, Admitted Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages and the Australian Bureau of Statistics. Eight years of data provided a sample size of 258,161 full-term women and their infants. The primary outcome was a composite outcome of neonatal mortality and morbidity as used in the Birthplace in England study.Results: Women who planned to give birth in a birth centre or at home were significantly more likely to have a normal labour and birth compared with women in the labour ward group. There were no statistically significant differences in stillbirth and early neonatal deaths between the three groups, although we had insufficient statistical power to test reliably for these differences.Conclusion: This study provides information to assist the development and evaluation of different places of birth across Australia. It is feasible to examine perinatal and maternal outcomes by planned place of birth using routinely collected linked data, although very large data sets will be required to measure rare outcomes associated with place of birth in a low risk population, especially in countries like Australia where homebirth rates are low. 2014 Homer et al.; licensee BioMed Central Ltd.
Dahlen, H.G., Downe, S., Kennedy, H.P. & Foureur, M. 2014, 'Is society being reshaped on a microbiological and epigenetic level by the way women give birth?', Midwifery.
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Homer, C.S., Thornton, C., Scarf, V.L., Ellwood, D.A., Oats, J.J., Foureur, M.J., Sibbritt, D., McLachlan, H.L., Forster, D.A. & Dahlen, H.G. 2014, 'Birthplace in New South Wales, Australia: an analysis of perinatal outcomes using routinely collected data.', BMC Pregnancy Childbirth, vol. 14, p. 206.
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The outcomes for women who give birth in hospital compared with at home are the subject of ongoing debate. We aimed to determine whether a retrospective linked data study using routinely collected data was a viable means to compare perinatal and maternal outcomes and interventions in labour by planned place of birth at the onset of labour in one Australian state.
Monk, A., Tracy, M., Foureur, M., Grigg, C. & Tracy, S. 2014, 'Evaluating Midwifery Units (EMU): a prospective cohort study of freestanding midwifery units in New South Wales, Australia.', BMJ Open, vol. 4, no. 10, p. e006252.
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To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in two freestanding midwifery units and two tertiary-level maternity units in New South Wales, Australia.
Dixon, L., Skinner, J. & Foureur, M. 2014, 'The emotional journey of labour-women's perspectives of the experience of labour moving towards birth.', Midwifery, vol. 30, no. 3, pp. 371-377.
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there has been minimal exploration of women's emotional flow during labour and towards birth. This research aimed to capture woman's remembered experiences of this process.
Catling-Paull, C., Coddington, R.L., Foureur, M.J. & Homer, C.S.E. 2013, 'Publicly funded homebirth in australia: A review of maternal and neonatal outcomes over 6 years', Medical Journal of Australia, vol. 198, no. 11, pp. 616-620.
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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.
Monk, A.R., Tracy, S., Foureur, M. & Barclay, L. 2013, 'Australian primary maternity units: Past, present and future', WOMEN AND BIRTH, vol. 26, no. 3, pp. 213-218.
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Foureur, M., Besley, K., Burton, G., Yu, N. & Crisp, J. 2013, 'Enhancing the resilience of nurses and midwives: Pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress', CONTEMPORARY NURSE, vol. 45, no. 1, pp. 114-125.
Tracy, S.K., Hartz, D.L., Tracy, M.B., Allen, J., Forti, A., Hall, B., White, J., Lainchbury, A., Stapleton, H., Beckmann, M., Bisits, A., Homer, C., Foureur, M., Welsh, A. & Kildea, S. 2013, 'Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial', LANCET, vol. 382, no. 9906, pp. 1723-1732.
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Dixon, L., Skinner, J.P. & Foureur, M. 2013, 'The emotional and hormonal pathways of labour and birth: integrating mind, body and behaviour', New Zealand College of Midwives Journal, vol. 48, no. 1, pp. 15-23.
Background: Women have described normal labour and birth in terms of their emotions. Major advances in knowledge have occurred within the sciences resulting in an understanding of emotions as prime directors of human behaviour which is orchestrated by neurohormones. Method: This paper focusses on key aspects of contemporary knowledge of childbirth physiology, neuroscience and behaviour. It integrates this understanding with womens descriptions of their emotions during labour. Findings: Neurohormones associated with labour and birth are designed to trigger a transformation in the body and behaviour and create an environment which supports both the mother and the baby. Hormones and emotions are intertwined and interconnected. Labour hormones are linked to the womans emotions and behaviour during labour and birth as well as the physical signs of labour. An interactive model is presented which explains labour in terms of both the physical effects and the emotional affects that women have described as part of their labour experience. The hypothesis for this model is that the hormones that initiate and sustain labour also cause the instinctual emotions that women feel, and the behaviour they exhibit, during spontaneous labour and birth.
Dahlen, H.G., Kennedy, H.P., Anderson, C.M., Bell, A.F., Clark, A., Foureur, M., Ohm, J.E., Shearman, A.M., Taylor, J.Y., Wright, M.L. & Downe, S. 2013, 'The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes.', Med Hypotheses, vol. 80, no. 5, pp. 656-662.
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There are many published studies about the epigenetic effects of the prenatal and infant periods on health outcomes. However, there is very little knowledge regarding the effects of the intrapartum period (labor and birth) on health and epigenetic remodeling. Although the intrapartum period is relatively short compared to the complete perinatal period, there is emerging evidence that this time frame may be a critical formative phase for the human genome. Given the debates from the National Institutes of Health and World Health Organization regarding routine childbirth procedures, it is essential to establish the state of the science concerning normal intrapartum epigenetic physiology. EPIIC (Epigenetic Impact of Childbirth) is an international, interdisciplinary research collaboration with expertise in the fields of genetics, physiology, developmental biology, epidemiology, medicine, midwifery, and nursing. We hypothesize that events during the intrapartum period - specifically the use of synthetic oxytocin, antibiotics, and cesarean section - affect the epigenetic remodeling processes and subsequent health of the mother and offspring. The rationale for this hypothesis is based on recent evidence and current best practice.
Mollart, L., Skinner, V.M., Newing, C. & Foureur, M. 2013, 'Factors that may influence midwives work-related stress and burnout.', Women Birth, vol. 26, no. 1, pp. 26-32.
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To determine the incidence and level of work-related stress and burnout in midwives and contributing and protective demographic factors that may influence those levels.
Dixon, L., Skinner, J. & Foureur, M. 2013, 'Women's perspectives of the stages and phases of labour.', Midwifery, vol. 29, no. 1, pp. 10-17.
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within childbirth there is a common and widely known explanation of labour and birth which describes and defines the birth process as stages and phases. The aim of this research was to determine whether the discourse of labour as stages and phases resonated with women who had experienced spontaneous labour and birth.
Monk, A.R., Tracy, S.K., Foureur, M. & Tracy, M. 2013, 'Evaluating midwifery units (EMU): lessons from the pilot study.', Midwifery, vol. 29, no. 8, pp. 845-851.
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this paper describes the pilot study that was undertaken to test the feasibility of the recruitment plan designed to recruit women who booked to give birth in two freestanding midwifery units in NSW, Australia. The pilot preceded the full prospective cohort study, Evaluating Midwifery Units (EMU), which aimed to examine the antenatal, birth and postnatal outcomes of women planning to give birth in freestanding midwifery units compared to those booked to give birth in tertiary level maternity units in Australia and New Zealand.
Stenglin, M. & Foureur, M. 2013, 'Designing out the Fear Cascade to increase the likelihood of normal birth.', Midwifery, vol. 29, no. 8, pp. 819-825.
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Hammond, A., Foureur, M., Homer, C.S.E. & Davis, D. 2013, 'Space, place and the midwife: Exploring the relationship between the birth environment, neurobiology and midwifery practice', Women and Birth, vol. 26, no. 4, pp. 277-281.
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Background: Research indicates that midwives and their practice are influenced by space and place and that midwives practice differently in different places. It is possible that one mechanism through which space and place influence midwifery practice is via neurobiological responses such as the production and release of oxytocin, which can be triggered by experiences and perceptions of the physical environment. Aim: To articulate the significance of space and place to midwifery and explore the relationship between the birth environment, neurobiology and midwifery practice. Discussion: Quality midwifery care requires the facilitation of trusting social relationships and the provision of emotionally sensitive care to childbearing women. The neuropeptide oxytocin plays a critical role in human social and emotional behaviour by increasing trust, reducing stress and heightening empathy, reciprocity and generosity. Principle conclusion: Through its role as a trigger for oxytocin release, the birth environment may play a direct role in the provision of quality midwifery care. 2013 Australian College of Midwives.
Homer, C.S.E., Besley, K., Bell, J., Davis, D., Adams, J., Porteous, A. & Foureur, M. 2013, 'Does continuity of care impact decision making in the next birth after a caesarean section (VBAC)? A randomised controlled trial', BMC Pregnancy and Childbirth, vol. 13.
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Background: Caesarean section (CS) has short and long-term health effects for both the woman and her baby. One of the greatest contributors to the CS rate is elective repeat CS. Vaginal birth after caesarean (VBAC) is an option for many women; despite this the proportion of women attempting VBAC remains low. Potentially the relationship that women have with their healthcare professional may have a major influence on the uptake of VBAC. Models of service delivery, which enable an individual approach to care, may make a difference to the uptake of VBAC. Midwifery continuity of care could be an effective model to encourage and support women to choose VBAC.Methods/Design: A randomised, controlled trial will be undertaken. Eligible pregnant women, whose most recent previous birth was by lower-segment CS, will be randomly allocated 1:1 to an intervention group or control group. The intervention provides midwifery continuity of care to women through pregnancy, labour, birth and early postnatal care. The control group will receive standard hospital care from different midwives through pregnancy, labour, birth and early postnatal care. Both groups will receive an obstetric consultation during pregnancy and at any other time if required. Clinical care will follow the same guidelines in both groups.Discussion: This study will determine whether midwifery continuity of care influences the decision to attempt a VBAC and impacts on mode of birth, maternal experiences with care and the health of the neonate. Outcomes from this study might influence the way maternity care is provided to this group of women and thus impact on the CS rate. This information will provide high level evidence to policy makers, health service managers and practitioners who are working towards addressing the increased rate of CS.Trial registration: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001214921. 2013 Homer et al.; licensee BioMed Central Ltd.
Atchan, M., Davis, D. & Foureur, M. 2013, 'The impact of the Baby Friendly Health Initiative in the Australian health care system: a critical narrative review of the evidence.', Breastfeed Rev, vol. 21, no. 2, pp. 15-22.
Studies have identified that the practices of maternity facilities and health professionals are crucial to women's experience of support and breastfeeding 'success'. The Baby Friendly Hospital Initiative (BFHI) was launched globally in 1991 to protect, promote and support breastfeeding. While a direct causal effect has not been established and critics suggest the rhetoric conflicts with women's lived experiences as new mothers, a positive association between the Initiative and breastfeeding prevalence is apparent. Internationally, impact studies have demonstrated that where the Initiative is well integrated, there is an increase in rates of breastfeeding initiation and, to a lesser extent, duration. In consideration of the known health risks associated with the use of artificial baby milks this would suggest that BFHI implementation and accreditation should be a desirable strategy for committed health facilities. However, a variation in both BFHI uptake and breastfeeding prevalence between nations has been reported. This narrative review critically discusses a variety of issues relevant to the uptake and support of breastfeeding and the BFHI, utilising Australia as a case study. Whilst it enjoys 'in principle' policy support, Australia also suffers from a lack of uniformity in uptake and perception of the benefits of BFHI at all levels of the health system. Australian and international studies have identified similar enablers and barriers to implementation.
Kassab, M., Foster, J.P., Foureur, M. & Fowler, C. 2012, 'Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age', COCHRANE DATABASE OF SYSTEMATIC REVIEWS, no. 12.
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Hartz, D.L., Foureur, M. & Tracy, S.K. 2012, 'Australian caseload midwifery: the exception or the rule.', Women Birth, vol. 25, no. 1, pp. 39-46.
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The aim of this paper is to review the clinical outcomes of descriptive and comparative cohort studies of the Australian caseload midwifery models of care that emerged during the late 1990s and early 2000s. These models report uniformly a decrease in caesarean section operation rates when compared to local, state and national rates, irrespective of the obstetric risk of the women cared for. These outcomes are in contrast to the findings of the randomised controlled trials and comparative cohort studies of caseload midwifery conducted, predominantly in the United Kingdom, in the mid to late 1990s. The Australian studies show that caseload midwifery is a model of care that is associated with lowered rates of caesarean section operations, and other obstetric intervention rates. The absence of definitive evidence of the effect of caseload midwifery, derived from published descriptive and comparative cohort studies, underlines the need for a sufficiently powered randomised controlled trial of caseload midwifery. The randomised controlled trial of caseload midwifery being undertaken in two major teaching hospitals in Australia will provide definitive answers relating to the effect of the caseload midwifery model of care for women of all risk in the Australian context.
Kassab, M., Sheehy, A., King, M., Fowler, C. & Foureur, M. 2012, 'A double-blind randomised controlled trial of 25% oral glucose for pain relief in 2-month old infants undergoing immunisation', INTERNATIONAL JOURNAL OF NURSING STUDIES, vol. 49, no. 3, pp. 249-256.
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Lennox, S. & Foureur, M. 2012, 'Developmental mentoring: New graduates' confidence grows when their needs shape the relationship', New Zealand College of Midwives Journal, vol. 46, no. June2012, pp. 26-31.
This paper describes a research project that explored group mentoring with four new graduate midwives and four experienced midwives.
Lennox, S., Jutel, A. & Foureur, M. 2012, 'The Concerns of Competent Novices during a Mentoring Year', Nursing Research and Practice, vol. Epub, pp. 1-9.
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In an innovative group mentoring approach, four experienced midwives mentored four new graduates during their first year of practice.
Homer, C.S., Ryan, C., Leap, N., Foureur, M., Teate, A. & Catling-Paull, C.J. 2012, 'Group versus conventional antenatal care for women.', Cochrane database of systematic reviews (Online), vol. 11.
Antenatal care is one of the key preventive health services used around the world. In most Western countries, antenatal care traditionally involves a schedule of one-to-one visits with a care provider. A different way of providing antenatal care is through a group model. The first objective was to compare the effects of group antenatal care versus one-to-one care on outcomes for women and their babies. The primary outcomes were preterm birth (birth occurring before 37 completed gestational weeks), low birthweight (less than 2500 g), small-for-gestational age (less than the tenth percentile for gestation and gender) and perinatal mortality. Secondary outcomes included psychological measures and satisfaction as well as labour and birth and postnatal outcomes.The second objective was to compare the effects of group care versus one-to-one care on care provider satisfaction. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 March 2012), contacted experts in the field and reviewed the reference lists of retrieved studies. All identified published, unpublished and ongoing randomised and quasi-randomised controlled trials comparing group antenatal care with conventional antenatal care were included. Cluster-randomised trials were eligible for inclusion but none were identified. Cross-over trials were not eligible. Two review authors independently assessed studies for inclusion and evaluated trial quality. Two authors extracted data. Data were checked for accuracy. We included two studies (1369 women). There were no statistically significant differences between women who received group antenatal care compared with standard one-to-one care in relation to the primary outcomes. In particular, there was no difference in the rate of preterm birth rate between the two groups (risk ratio (RR) 0.87; 95% confidence interval (CI) 0.47 to 1.60; two trials; N = 1315) and the proportion of low birthweight (less than 2500 g) babies was similar between the groups (RR 1.03; 95% CI 0.73 to 1.46; two trials; N = 1315).Satisfaction was rated highly in women who were allocated to group antenatal care but only measured in one trial. In this trial, the mean satisfaction with care in group antenatal care was almost five times higher compared with those allocated to standard care (N = 993). A number of outcomes related to stress, distress and depression were reported in one trial. There were no differences between the groups in any of these outcomes.There were no data available on the effects of group antenatal care on care provider satisfaction. The available evidence suggests that group antenatal care is positively viewed by women with no adverse outcomes for themselves or their babies. This review is limited owing to the small number of studies/women and the majority of the analyses are based on a single study. More research is required to determine if group antenatal care is associated with significant benefits.
Kassab, M.I., Roydhouse, J.K., Fowler, C. & Foureur, M. 2012, 'The effectiveness of glucose in reducing needle-related procedural pain in infants.', J Pediatr Nurs, vol. 27, no. 1, pp. 3-17.
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This systematic review examined the effectiveness of glucose in relieving needle-associated pain in infants. Meta-analysis was not undertaken, and there was variation in dose, administration method, concentration, and outcome measurement. Glucose was more effective than placebo in relieving infant pain as measured by behavioral outcomes, but there were mixed findings for physiological outcomes. Based on these findings, 25%-50% glucose appears effective for infant pain management.
Catling-Paull, C., Foureur, M.J. & Homer, C.S.E. 2012, 'Publicly-funded homebirth models in Australia', Women and Birth, vol. 25, no. 4, pp. 152-158.
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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.
Fenwick, J., Hammond, A., Raymond, J., Smith, R., Gray, J., Foureur, M., Homer, C. & Symon, A. 2012, 'Surviving, not thriving: A qualitative study of newly qualified midwives' experience of their transition to practice', Journal of Clinical Nursing, vol. 21, no. 13-14, pp. 2054-2063.
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Aim and objectives. The study explored the experiences of newly qualified midwives and described the factors that facilitated or constrained their development during the transition from student to registered midwife. Background. Knowledge of the transition to midwifery practice remains limited. Design and Method. A qualitative descriptive approach was used. Sixteen graduates from one Australian University participated in a tape-recorded interview. Thematic analysis was used to analyse the data set. Results. The metaphor of 'The Pond', an environment that consists of layers of life and can be both clear and peaceful or murky and infested, was used to describe new midwives perceptions of the context and culture of hospital-based maternity care. For some, 'The Pond' was a harsh environment that often became toxic. The 'Life-raft' metaphor was used to describe the importance of midwife-to-midwife relationships. The theme of 'Swimming' captured the consequence of positive interactions with colleagues and a supportive environment, whilst 'Sinking' described the consequence of poor relationships with midwives and a difficult working environment. Conclusion. The study highlights the importance of positive midwife-to-midwife relationships on the transition from student to registered midwife. There was also evidence that continuity with women and midwifery colleagues enhanced confidence and restored faith in normal birth. At the same time, it was clear that the midwifery culture of some institutions remains highly contested with midwives struggling to provide woman-centred care and often challenged by the risk-averse nature of maternity care. Relevance to Clinical Practice. Whilst further work is required, the findings provide a deeper understanding of individual midwives' transition period. The importance of forming longitudinal relationships not only with women but with midwifery colleagues is highlighted. Developing continuity models that adequately support graduates and student's needs are likely to assist in addressing practices issues in both the academic and clinical setting. 2012 Blackwell Publishing Ltd.
Davis, D.L., Raymond, J.E., Clements, V., Adams, C., Mollart, L.J., Teate, A.J. & Foureur, M.J. 2012, 'Addressing obesity in pregnancy: the design and feasibility of an innovative intervention in NSW, Australia.', Women Birth, vol. 25, no. 4, pp. 174-180.
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Obesity amongst women of child bearing age is increasing at an unprecedented, rate throughout the Western world. This paper describes the design of an innovative, collaborative, antenatal intervention that aims to assist women to manage their weight during pregnancy and, presents aspects of the programme evaluation.
Homer, C.S., Ryan, C., Leap, N., Foureur, M., Teate, A. & Catling-Paull, C.J. 2012, 'Group versus conventional antenatal care for women.', Cochrane Database Syst Rev, vol. 11, p. CD007622.
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Antenatal care is one of the key preventive health services used around the world. In most Western countries, antenatal care traditionally involves a schedule of one-to-one visits with a care provider. A different way of providing antenatal care is through a group model.
Kassab, M., Foster, J.P., Foureur, M. & Fowler, C. 2012, 'Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age.', Cochrane Database Syst Rev, vol. 12, p. CD008411.
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Administration of oral sucrose or glucose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for needle-related procedural pain relief in infants.
Lennox, S., Jutel, A. & Foureur, M. 2012, 'The Concerns of Competent Novices during a Mentoring Year.', Nurs Res Pract, vol. 2012, p. 812542.
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In an innovative group mentoring approach, four experienced midwives mentored four new graduates during their first year of practice. The new graduates were in practice as case-loading registered midwives having completed a three year Bachelor of Midwifery degree. Detailed data about the new graduates' concerns were collected throughout the year of the mentoring project. A range of practice areas-administrative, working environment, professional culture, clinical issues and the mentor group itself-were prominent issues. New graduates were concerned about their own professional development and about relationships with others particularly relationships within the hospital. Technical questions focussed more on craft knowledge that develops through experience than on clinical skills or knowledge. Identifying these concerns provides a foundation for mentors, preceptors and those designing professional development support programmes for the first year of practice. It may be that new graduate midwives educated in a profession with a narrowly defined scope of practice have a different range of concerns to new graduates who have wider scopes of practice. The use of a group model of mentoring for supporting new graduate midwives proved stimulating for mentors and highly supportive of new graduates.
Davis, D., Foureur, M., Clements, V., Brodie, P. & Herbison, P. 2012, 'The self reported confidence of newly graduated midwives before and after their first year of practice in Sydney, Australia.', Women Birth, vol. 25, no. 3, pp. e1-10.
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Graduates from a new, 3-year Bachelor of Midwifery program joined those educated through the 1 year, postgraduate route (for those already qualified as nurses) for the first time in New South Wales (NSW) Australia in 2007. Many hospitals offer transition support programs for new graduates during their first year of practice though there is little evidence available to inform these programs.
Homer, C.S.E., Johnston, R. & Foureur, M.J. 2011, 'Birth after caesarean section: Changes over a nine-year period in one Australian state', Midwifery, vol. 27, no. 2, pp. 165-169.
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Objectives: to describe the outcomes related to birth after a caesarean section (CS) in one Australian state, New South Wales (NSW), over a nine-year period. The objectives were to determine whether changes had occurred in the rates of attempted and successful vaginal birth after caesarean section (VBAC), induction of labour, place of birth, admission to special care or neonatal intensive care nursery and perinatal mortality. Design and setting: cross-sectional analytic study of hospital births in New South Wales using population-based data from 1998-2006. Participants: women experiencing the next birth after a CS where: the total number of previous CS was 1; the presentation at birth was vertex; it was a singleton pregnancy; and, the estimated gestational age was greater than or equal to 37 weeks. A total of 53,455 women met these criteria. Measurements: data were obtained from NSW Health Department's Midwives Data Collection (MDC). The MDC includes all live births and stillbirths of at least 20 weeks gestation or 400. g birth weight in the state. Findings: over the nine-year period, the rate of vaginal birth after caesarean section declined significantly (31-19%). The proportion of women who 'attempted a vaginal birth' also declined (49-35%). Of those women who laboured, the vaginal birth rate declined from 64% to 53%. Babies whose mothers 'attempted' a VBAC were significantly less likely to require admission to a special care nursery (SCN) or neonatal intensive care (NICU). The perinatal mortality rate in babies whose mothers 'attempted' a VBAC was higher than those babies born after an elective caesarean section although the absolute numbers are very small. Key conclusions: rates of VBAC have declined over this nine-year period. Rates of neonatal mortality and proxy measures of morbidity (admission to a nursery) are generally in the low range for similar settings. Implications for practice: decisions around the next birth after CS are complex. Efforts to keep the first birth normal and support women who have had a CS to have a normal birth need to be made. More research to predict which women are likely to achieve a successful VBAC and the most effective ways to facilitate a VBAC is essential. Midwives have a critical role to play in these endeavours. 2009 Elsevier Ltd.
Catling-Paull, C., Johnston, R., Ryan, C., Foureur, M.J. & Homer, C.S.E. 2011, 'Clinical interventions that increase the uptake and success of vaginal birth after caesarean section: A systematic review', Journal of Advanced Nursing, vol. 67, no. 8, pp. 1646-1661.
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Aim. The aim of this study was to review clinical interventions that increase the uptake and/or the success rates of vaginal birth after caesarean section. Background. Repeat caesarean section is the main reason for the increase in surgical births. The risk of uterine rupture in women who have prior caesarean sections prevents many clinicians from recommending vaginal birth after caesarean. Despite this, support for vaginal birth after caesarean continues. Data sources. A search of five databases and a number of relevant professional websites was undertaken up to December 2008. Review methods. A systematic review of quantitative studies that involved a comparison group and examined a clinical intervention for increasing the uptake and/or the success of vaginal birth after caesarean section was undertaken. An assessment of quality was made using the Critical Skills Appraisal Programme. Results. Induction of labour using artificial rupture of membranes, prostaglandins, oxytocin infusion or a combination, was associated with lower vaginal birth rates. Cervical ripening agents such as prostaglandins and transcervical catheters may result in lower vaginal birth rates compared with spontaneous labour. The impact of epidural anaesthesia in labour on vaginal birth after caesarean success is inconclusive. X-ray pelvimetry is associated with reduced uptake of vaginal birth after caesarean and higher caesarean section rates. Scoring systems to predict likelihood of vaginal birth are largely unhelpful. There is insufficient data in relation to vaginal birth after caesarean section between different closure methods for the primary caesarean section. Conclusion. Clinical factors can affect vaginal birth after caesarean uptake and success. 2011 The Authors. Journal of Advanced Nursing 2011 Blackwell Publishing Ltd.
Catling-Paull, C., Johnston, R., Ryan, C., Foureur, M.J. & Homer, C.S. 2011, 'Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: A systematic review', Journal of Advanced Nursing, vol. 67, no. 8, pp. 1662-1676.
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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.
Foureur, M.J., Leap, N., Davis, D.L., Forbes, I.F. & Homer, C.S.E. 2011, 'Testing the birth unit design spatial evaluation tool (BUDSET) in Australia: A pilot study', Health Environments Research and Design Journal, vol. 4, no. 2, pp. 36-60.
Objective: To pilot test the Birth Unit Design Spatial Evaluation Tool (BUDSET) in an Australian maternity care setting to determine whether such an instrument can measure the optimality of different birth settings. Background: Optimally designed spaces to give birth are likely to influence a woman's ability to experience physiologically normal labor and birth. This is important in the current industrialized environment, where increased caesarean section rates are causing concerns. The measurement of an optimal birth space is currently impossible, because there are limited tools available. Methods: A quantitative study was undertaken to pilot test the discriminant ability of the BUDSET in eight maternity units in New South Wales, Australia. Five auditors trained in the use of the BUDSET assessed the birth units using the BUDSET, which is based on 18 design principles and is divided into four domains (Fear Cascade, Facility, Aesthetics, and Support) with three to eight assessable items in each. Data were independently collected in eight birth units. Values for each of the domains were aggregated to provide an overall Optimality Score for each birth unit. Results: A range of Optimality Scores was derived for each of the birth units (from 51 to 77 out of a possible 100 points). The BUDSET identified units with low-scoring domains. Essentially these were older units and conventional labor ward settings. Conclusion: The BUDSET provides a way to assess the optimality of birth units and determine which domain areas may need improvement. There is potential for improvements to existing birth spaces, and considerable improvement can be made with simple low-cost modifications. Further research is needed to validate the tool. 2011, Vendome Group, LLC. All rights reserved.
Sheehy, A., Foureur, M., Catling-Paull, C. & Homer, C. 2011, 'Examining the content validity of the birthing unit design spatial evaluation tool within a woman-centered framework.', J Midwifery Womens Health, vol. 56, no. 5, pp. 494-502.
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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.
Atchan, M., Foureur, M. & Davis, D. 2011, 'The decision not to initiate breastfeeding--women's reasons, attitudes and influencing factors--a review of the literature.', Breastfeed Rev, vol. 19, no. 2, pp. 9-17.
Breastfeeding is the biological feeding norm for human babies. Encouraging breastfeeding is a primary health promotion strategy, with studies demonstrating the risks of artificial baby milks. Each year approximately 10% of the women who give birth in New South Wales decide not to initiate breastfeeding, and the demographic characteristics of this group of women have previously been identified. This paper reviews the literature to explore the factors that influence women's decisions about breastfeeding, and their reasons for not initiating breastfeeding. The review revealed there are relatively few studies that explore the experiences of women who decide not to initiate breastfeeding, especially in the Australian context.
Patterson, J., Foureur, M. & Skinner, J.P. 2011, 'Patterns of transfer in labour and birth in rural New Zealand', Rural and Remote Health, vol. 11, no. 1710, pp. 1-15.
For many women, and particularly rural women, birthing locally and within their own community is important for personal, social and/or cultural reasons. If concerns about the woman or her baby mean transfer to a secondary or tertiary facility is necessary, this can be disruptive and stressful, especially if road transfer is complicated by terrain, weather or distance, as is often the case in rural New Zealand. The objective of this study was to explore the number of and reason for transfers during labour and birth for well women, close to full term, from primary rural maternity facilities to specialist care in rural New Zealand. Methods: This retrospective survey of 45 rural maternity units in the North and South Islands of New Zealand was conducted over a 2 year period ending on 30 June 2006. The participants were the 4678 women who began labour in a rural facility during this time period. Results: The survey response rate was 66.6%. The data revealed that 16.6% of women who commenced labour in a rural unit were transferred in labour or within 6 hours of birth; 3% of babies born in rural units were transferred after birth and up to 7 days post-birth. The primary reason for maternal transfer was slow progress in labour (49.67%). Of the 123 babies transferred, this was most often due to respiratory problems (43%). Key features of the rural context (times and distances to be travelled, geological and climatic characteristics, types of transport systems and availability of local assistance) influenced the timeliness of the decision to transfer. Conclusions: Within New Zealands regionalised perinatal system, midwives make cautious decisions about transfer, taking into account the local rural local circumstances, and also the topography as it impacts on transport.
Kassab, M., Fowler, C.M. & Foureur, M. 2011, 'Managing immunisation pain in infants', Australian Journal of Child and Family Health Nursing, vol. 8, no. 3, pp. 4-9.
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There exists an ethical imperative to ensure the wellbeing of infants undergoing painful procedures, even procedures of short duration. The use of suitable, non-pharmacological pain-relieving measures such as sweet-tasting solutions (for example, sucrose of glucose) should be considered.
Patterson, J.A., Foureur, M. & Skinner, J.P. 2011, 'Reply to Comment on: Patterns of transfer in labour and birth in rural New Zealand.', Rural Remote Health, vol. 11, no. 3, p. 1877.
Patterson, J.A., Foureur, M. & Skinner, J.P. 2011, 'Patterns of transfer in labour and birth in rural New Zealand.', Rural Remote Health, vol. 11, no. 2, p. 1710.
For many women, and particularly rural women, birthing locally and within their own community is important for personal, social and/or cultural reasons. If concerns about the woman or her baby mean transfer to a secondary or tertiary facility is necessary, this can be disruptive and stressful, especially if road transfer is complicated by terrain, weather or distance, as is often the case in rural New Zealand. The objective of this study was to explore the number of and reason for transfers during labour and birth for well women, close to full term, from primary rural maternity facilities to specialist care in rural New Zealand.
Catling, C., Johnston, R.A., Ryan, C., Foureur, M. & Homer, C.S. 2010, 'Interventions for increasing the uptake or success of vaginal birth after caesarean section: A Technical Report', pp. 1-94.
Skinner, J.P. & Foureur, M. 2010, 'Consultation, referral, and collaboration between midwives and obstetricians: lessons from New Zealand.', J Midwifery Womens Health, vol. 55, no. 1, pp. 28-37.
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There has been substantial growth in the provision of midwifery-led models of care, yet little is known about the obstetric consultation and referral practices of these midwives or the quality of the collaboration between midwives and obstetricians. This study aimed to describe these processes as they are practised in New Zealand, where midwifery-led maternity care is the dominant model. A total population postal survey was conducted that included 649 New Zealand midwives who provided midwifery-led care in 2001. There was a 56.5% response rate, describing care for 4251 women. Within this cohort, there was a 35% consultation rate and 43% of these women had their lead carer role transferred to an obstetrician. However, the midwives continued to provide care in collaboration with obstetricians for 74% of transferred women. Seventy-two percent of midwives felt that they were well supported by the obstetricians to continue care. Midwifery-led care is reasonable for the general population of childbearing women, and a 35% consultation rate can be seen as a benchmark for this population. Midwives can, when well supported, provide continuity of care for women who experience complexity during pregnancy and/or birth. Collaboration with obstetricians is possible, but there needs to be further work to describe what successful collaboration is and how it might be fostered.
Foureur, M., Davis, D., Fenwick, J., Leap, N., Iedema, R., Forbes, I. & Homer, C.S.E. 2010, 'The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model', Midwifery, vol. 26, no. 5, pp. 520-525.
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Recent advances in cross-disciplinary studies linking architecture and neuroscience have revealed that much of the built environment for health-care delivery may actually impair rather than improve health outcomes by disrupting effective communication and increasing patient and staff stress. This is also true for maternity care provision, where it is suggested that the design of the environment can also impact on the experiences and outcomes for birthing women.The aim of this paper is to describe the development of a conceptual model based on literature and understandings of design, communication, stress and model of care. The model explores potential relationships among a set of key variables that need to be considered by researchers wishing to determine the characteristics of optimal birth environments in relation to birth outcomes for women and infants. The conceptual model hypothesises that safe satisfying birth is reliant on the level of stress experienced by a woman and the staff around her, stress influences the quality of communication with women and between staff, and this process is mediated by the design of the birth unit and model of care.The conceptual model is offered as a starting point for researchers who have an appreciation of the complexity of birth and the ability to bring together colleagues from a range of disciplines to explore the pre-requisites for safe and effective maternity care in new ways. 2010 Elsevier Ltd.
Foureur, M.J., Leap, N., Davis, D.L., Forbes, I.F. & Homer, C.S.E. 2010, 'Developing the birth unit design spatial evaluation tool (BUDSET) in Australia: A qualitative study', Health Environments Research and Design Journal, vol. 3, no. 4, pp. 43-57.
Objective: To develop a tool known as the Birth Unit Design Spatial Evaluation Tool (BUDSET), to assess the optimality of birth unit design. Background: The space provided for childbirth influences the physiology of women in labor. Optimal birth spaces are likely to enable women to have physiologically normal labor and birth. The measurement of an optimal birth space is currently impossible, because limited tools are available. Research into optimal birth unit design is also limited. Methods: The BUDSET was developed using a qualitative study. Data collection included an extensive literature review, interviews with key informants (architects, midwife clinicians, and researchers) and an expert panel. A Pattern Language format was used to synthesize the literature and data obtained from the key informants. Results: The BUDSET is based on 18 design principles and is divided into four domains (Fear Cascade; Facility; Aesthetics; Support) with three to eight assessable items in each. Conclusion: Birth units must be designed so that they facilitate and support the physiology of normal childbirth. The BUDSET may provide a way to assess the optimality of birth units and determine which domain areas may need to be improved.
Cooke, H., Foureur, M., Kinnear, A., Bisits, A. & Giles, W. 2010, 'The development and initiation of the NSW Department of Health interprofessional Fetal welfare Obstetric emergency Neonatal resuscitation Training project', AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY, vol. 50, no. 4, pp. 334-339.
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Foureur, M., Ryan, C.L., Nicholl, M. & Homer, C. 2010, 'Inconsistent evidence: analysis of six national guidelines for vaginal birth after cesarean section.', Birth, vol. 37, no. 1, pp. 3-10.
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Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice.
Dixon, L. & Foureur, M. 2010, 'The vaginal examination during labour. Is it of benefit or harm?', New Zealand College of Midwives Journal, vol. 42, no. May 2010, pp. 21-26.
Giving birth is an important life event and care practices that occur during labour and birth can have a lasting influence on the mother and the family (Beech & Phipps, 2004). The use of regular, routine vaginal examination to assess the progress of labour is one such care practice. There are two ways of viewing the vaginal examination during labour. The first regards the vaginal examination as a physically invasive intervention which can have adverse psychological consequences (Kitzinger, 2005). The second sees vaginal examination as an essential clinical assessment tool that provides the most exact measure of labour progress (Enkin et al., 2000). This paper explores thes two viewpoints in more detail and discusses the benefits versus the harms of undertaking a vaginal examination during labour. Midwives use a variety of skills and observations to assess labour progress.
Maude, R., Lawson, J. & Foureur, M. 2010, 'Auscultation - The Action of Listening', New Zealand College of Midwives Journal, vol. 43, no. 1, pp. 13-18.
The article focuses on the historical development of auscultation and listening to fetal heart beats. It mentions that auscultation defines as the action of listening to the sounds inside the body. It says that the use stethoscope in midwifery practice was introduced in 1819 wherein listening to fetal heart sounds helps determine the well-being of the fetus. It adds that intermittent auscultation was recommended for fetal heart monitoring by the professional evidence-based guideline
Homer, C.S.E., Catling-Paull, C.J., Sinclair, D., Faizah, N., Balasubramanian, V., Foureur, M.J., Hoang, D.B. & Lawrence, E. 2010, 'Developing an interactive electronic maternity record', British Journal of Midwifery, vol. 18, no. 6, pp. 384-389.
Women have a strong need to be involved in their own maternity care. Pregnancy hand-held records encourage women's participation in their maternity care; gives them an increased sense of control and improves communication among care providers. They have been successfully used in the UK and New Zealand for almost 20 years. Despite evidence that supports the use of hand-held records, widespread introduction has not occurred in Australia. The need for an electronic version of pregnancy hand-held records has become apparent, especially after the introduction of the Electronic Medical Record in Australia. A personal digital assistant (PDA) was developed as an interactive antenatal electronic maternity record that health-care providers could use in any setting and women could access using the internet. This article will describe the testing of the antenatal electronic maternity record.
Maude, R. & Foureur, M. 2009, 'Intrapartum fetal heart rate monitoring: using audit methodology to identify areas for research and practice improvement', New Zealand College of Midwives Journal, vol. 40, no. 1, pp. 24-30.
The purpose of the study was to explore the fetal heart rate monitoring practices of midwives and doctors to determine compliance with an evidence-based guideline for fetal heart rate monitoring endorsed by one New Zealand (NZ) District Health Board (DHB). A retrospective audit of 193 randomly selected medical records was undertaken over six months (July-December 2006). The audit revealed deficiencies in choice of fetal heart rate monitoring modality, monitoring technique, documentation, communication and use of a standardised approach and language for interpreting cardiotocograph (CTG) traces especially the description and categorisation of the four main fetal heart rate features. Multidisciplinary education and a standardised template for reporting CTGs were key recommendations.
Wilton, D.C. & Foureur, M. 2009, 'A survey of folic acid use in primigravid women', Women and Birth, vol. 23, no. 2, pp. 67-73.
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A convenience sample of 320 consecutive primigravid women attending the antenatal clinic of a large Sydney tertiary referral hospital were invited to take part in a survey of folic acid use in pregnancy. The aim of the survey was to determine the number of primigravid women who commenced taking folic acid supplementation at least 1 month prior to conception. In addition the survey sought information on women's source of knowledge about the need for folic acid in pregnancy and whether their pregnancy was planned or unplanned. 295 women qualified to be included in the survey. While 88.1% of women took folic acid at some time prior to and/or during the first trimester, only 23.4% were found to have taken folic acid at least 1 month prior to conception. Of women with a planned birth only 34.5% commenced folic acid prior to conception. This survey adds further weight to the decision of the Australian Government to mandate for fortification of bread-making flour with folic acid, due to commence in September 2009. However, even with folic acid fortified food, health professionals need to continue to advise women to take supplements prior to conception and for at least 12 weeks into their pregnancy to prevent neural tube defects.
Foureur, M., Brodie, P. & Homer, C. 2009, 'Midwife-centered versus woman-centered care: a developmental phase?', Women Birth, vol. 22, no. 2, pp. 47-49.
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Harding, D. & Foureur, M. 2009, 'New Zealand and Canadian Midwives' Use of Complementary and Alternative Medicine (CAM)', New Zealand College of Midwives Journal, vol. 40, no. 1, pp. 7-12.
Complementary and alternative medicine (CAM) is widely used by women and midwives in maternity care despite the lack of strong evidence for safety or efficacy. The purpose of this research was to investigate how midwives in primary midwifery care practice in two countries use CAM.
Duke, J., McBride-Henry, K., Walsh, K. & Foureur, M. 2009, 'The expectations of two New Zealand health services of the role of Clinical Chairs in Nursing and Midwifery.', Contemp Nurse, vol. 31, no. 2, pp. 129-141.
Clinical Professoriate positions within nursing or midwifery in New Zealand are a relatively recent development. One New Zealand University worked collaboratively to establish two joint clinical Professorial appointments with different District Health Boards. Each position had unique mandates around research platforms, and differing operational responsibilities. This paper reports on the qualitative component of a larger study that aimed to examine the research culture, and the role of Clinical Chairs, within the two District Health Boards. This phase of the research involved semi-structured interviews with senior staff from the DHB to explore their experiences of working with the Clinical Professor. Themes that emerged revolved around expectations of the role during its development, and the subsequent perceived outcomes. The need for objective measures of the roles' impact on clinical outcomes emerged as a key impression from the participants. Future research that focuses on measurements of outcomes attributable to the roles will ensure their sustainability over time.
Mollart, L., Newing, C. & Foureur, M. 2009, 'Midwives' emotional wellbeing: impact of conducting a structured antenatal psychosocial assessment (SAPSA).', Women Birth, vol. 22, no. 3, pp. 82-88.
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To investigate the impact of conducting structured antenatal psychosocial assessments (SAPSA) on midwives' emotional wellbeing. The SAPSA includes screening and assessment tools for domestic violence, childhood trauma, drug and alcohol use, depression, and vulnerability factors.
McBride-Henry, K. & Foureur, M. 2008, 'Organisational culture, medication administration and the role of nurses.', Practice Development in Healthcare, vol. 5, no. 4, pp. 208-222.
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Medication administration is a critical aspect of nursing practice, and has significant implications for the safety of the patients we care for. This research study was designed to identify ways of enhancing patient safety during the administration of medications within the New Zealand context. We employed a multi-method approach that included a survey using the Safety Climate Survey tool, focus groups and three clinical practice development groups. The outcomes of this study indicate that practice development initiatives, such as the ones outlined in this project, can have a positive effect on nurses' perceptions of organisational safety, which in turn has been demonstrated to have a positive impact on patient safety (Pronovost et al., 2003).
Forbes, I., Homer, C.S., Foureur, M. & Leap, N. 2008, 'Birthing Unit Designs', World Health Design, vol. 1, no. 3, pp. 47-53.
Lennox, S., Skinner, J. & Foureur, M. 2008, 'Mentorship, preceptorship and clinical supervision: three key processes for supporting midwives', New Zealand College of Midwives Journal, vol. 39, no. October, pp. 7-12.
New Zealand midwives are increasingly seeking and receiving professional support in clinical practice. This support is gaining acceptance within the profession and is now underpinned by government funding. There are a variety of ways in which support can be provided and this review of the literature describes three main approaches: mentoring, preceptorship and clinical supervision. These three key processes may be undertaken by all midwives whether new to practice or new to New Zealand and also by those who wish ongoing support and development.
Foureur, M. 2008, 'Der ideale Kreibsaal?', Deutsche Hebammen-Zeitschrift: Fachblatt fuer ..., vol. 6, pp. 10-12.
Walsh, K., Duke, J., Foureur, M. & Macdonald, L. 2007, 'Designing an effective evaluation plan: a tool for understanding and planning evaluations for complex nursing contexts.', Contemp Nurse, vol. 25, no. 1-2, pp. 136-145.
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With the increasing emphasis on the development of nursing, evidence based practice, practice development and new and extended nursing roles, nurses are faced with the challenge of developing effective evaluation practices in an increasingly complex health care environment. This complexity has seen a number of evaluation methodologies and methods used in health care and nurses in clinical settings may find it difficult to know what approach or approaches best apply to their context. Given that evaluation of nursing innovations and interventions can have political, practical and fiscal consequences it is important that nurses have a broad understanding of evaluation, why it is important, the various types of evaluation methods and methodologies as well as some way of working through this complexity in order to develop evaluation plans and practices that best meet their needs. This paper explores a number of common types of evaluation methodologies and aims to assist nurses to better understand the 'why' and the 'how' of evaluation. In addition the paper describes the development of an evaluation tool which aims to assist nurses to develop effective evaluation plans that will best meet their evaluation needs.
Maude, R. & Foureur, M. 2007, 'It's beyond water: Stories of women's experience of using water for labour and birth', Women and Birth, vol. 20, no. 1, pp. 17-24.
Qualitative descriptive study of women's experiences of using water for labour and birth based on analysis of in depth interviews. Revealed women use water immersion during labour and birth for many reasons other than for pain relief therefore studies using the RCT method to investigate the effectiveness of water for pain relief in labour have asked the wrong question of women. Provides a new research agenda and adds to the knowledge of this aspect of clinical practice. Co-authored with Robyn Maude who was my student undertaking a Masters research programme.
McBride-Henry, K. & Foureur, M. 2007, 'A secondary care nursing perspective on medication administration safety.', J Adv Nurs, vol. 60, no. 1, pp. 58-66.
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This paper is a report of a study to explore how nurses in a secondary care environment understand medication administration safety and the factors that contribute to, or undermine, safe practice during this process.
Foureur, M., Bush, R., Duke, J. & Walton, C. 2007, 'Poetry, A Reflective Practice tool for Nurses and Midwives.', Practice Development in Healthcare, vol. 6, no. 4, pp. 203-212.
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This article describes the practice of a ?poet-in-residence? in a tertiary hospital in New Zealand, a country with a unique bicultural foundation. During her residency, the poet worked with hospital staff to gain insight into how nurses and midwives contribute to health outcomes. As well as creating 12 poems which make the work of nurses and midwives more visible, the poet provided poetry readings in two clinical areas and conducted a reflective practice exercise using the co-creation of poetry, with a group of newly graduated nurses. This residency demonstrated the importance of connecting the world of science and technology with the world of lived experience and how poetry can help nurses and midwives to express the complexity of human care practice
McBride-Henry, K. & Foureur, M. 2006, 'Medication administration errors: understanding the issues.', Aust J Adv Nurs, vol. 23, no. 3, pp. 33-41.
This paper surveys current literature related to medication administration errors, the role of nurses in such errors, and current initiatives that are underway within New Zealand to address this aspect of patient safety.
Barton, J., Don, M. & Foureur, M. 2004, 'Nurses and midwives pain knowledge improves under the influence of an acute pain service', Acute Pain, vol. 6, no. 2, pp. 47-51.
A recent survey of nurses? and midwives? pain knowledge and attitudes demonstrated that those working regularly with an acute pain service were more knowledgeable about analgesics, non-drug pain management and addiction issues. An acute pain service was shown to have a positive influence on pain management practice. A 29-item pain knowledge and attitudes questionnaire which also included questions relating to the impact of an acute pain service was distributed to 600 nurses and midwives. A response rate of 48% (286 valid responses) was achieved. Nurses and midwives who were unaware of an acute pain service in their organisation had significantly lower scores on knowledge about pain management, particularly in relation to the analgesia choices made. This data indicates that an acute pain service has an important influence within health care organisations and can be utilised to lead advancement in pain management practice.
Levine, M., edelstein, J. & Foureur, M. 2003, 'The Relationship between Pregnancy Planning and Breastfeeding Duration', New Zealand College of Midwives Journal, vol. 29, no. 1, pp. 20-22.
This exploratory study, using a convenience sample of 102 primiparous women in New Zealand, examined the relationship between pregnancy planning and duration of breastfeeding. These women, who had chosen to exclusively breastfeed their infants, responded to a two-part survey: Part I self administered on the day of discharge from hospital; Part II completed during a telephone interview at 6 weeks postpartum. Results: No relationship was found between planning of pregnancy and duration of exclusive breastfeeding. At 6 weeks postpartum, 66 (65%) were exclusively breastfeeding and 34 (35%) were not. Women who had completed 12th grade were significantly more likely to exclusively breastfeed at 6 weeks postpartum than women who had not completed high school (X2= 5.38, p = 0.02).
Jull, A. & Foureur, M. 2003, 'Letter to the editor', Nursing Praxis in New Zealand, vol. 19, no. 2, pp. 53-55.
A letter critiquing an article in a previous issue of the journal that described case control studies. The letter pointed out errors in the article and proposed that research without adequate controls provides less than robust evidence of effectiveness of practice interventions and should be presented with its limitations clearly articulated.
Foureur, M. 2002, 'Randomised controlled trials in nursing and midwifery: an interview with Maralyn Foureur. Interview by Pamela J. Wood.', Nurs Prax N Z, vol. 18, no. 1, pp. 4-16.
Randomised controlled trials are considered to be one of the best research designs for determining effective care in the clinical setting. Relatively few randomised controlled trials, however, have been carried out in nursing or midwifery practice, so few examples of the practical realities of this research methodology are readily accessible. This is the sixth article in a series based on interviews with nursing and midwifery researchers, designed to offer the beginning researcher a first-hand account of the experience of using particular methodologies. This article focuses on the randomised controlled trial as experienced by Maralyn Foureur (RGON, RM, BA, Grad Dip Clin Epidem, PhD) who used this methodology to demonstrate the effectiveness of a continuity of care model in midwifery practice.
Shepherd, L. & Foureur, M. 2001, 'Introduction of night-lights to reduce falls on an Assessment, Treatment and Rehabilitation Unit', Australasian Journal of Rehabilitation Nursing, vol. 1, pp. 2-3.

Reports

Fisher, K., Foureur, M. & Hawley, J. Capital and Coast DHB 2005, Maternity and Gynaecology Report 2004, pp. 3-98, Wellington, New Zealand.
Analysis of Maternity and Gynaecology Service processes and outcomes. Recommendations for practice and policy changes made. Co-authored with Keith Fisher and Jackie Hawley.
Farquhar, C., Lethaby, A., Guilliland, K., Cole, S., Foureur, M., Buist, R., Banks, M., Waller, N. & Yates, A. New Zealand Guidelines Group 2004, Care of Women with Breech or Previous Caesarean Birth- Evidence-based Best Practice Guideline, Evidence Based Practice Guideline, pp. 1-106, Wellington, New Zealand.
Member of the NZ Guidelines Group to develop a Ministry of Health Commissioned Guideline. This was a multidisciplinary group who worked for two years reviewing the evidence and preparing a summary and then developing the guideline. The guideline is available from infor@nzgg.org.nz or www.nzgg.org.nz

Northern Sydney Local Health District

Central Coast Local Health District