Turkmani, S, Homer, CSE & Dawson, A 2019, 'Maternity care experiences and health needs of migrant women from female genital mutilation-practicing countries in high-income contexts: A systematic review and meta-synthesis.', Birth.View/Download from: Publisher's site
Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for nontherapeutic indications. Due to changing patterns of migration, clinicians in high-income countries are seeing more women from countries where the practice is prevalent. This review aims to understand the sociocultural and health needs of these women and identify opportunities to improve the quality of maternity care for women with FGM.We undertook a systematic review and meta-synthesis of peer-reviewed primary qualitative research to explore the experience and needs of migrant women with FGM receiving maternity care. A structured search of nine databases was undertaken, screened papers appraised, and a thematic analysis undertaken on data extracted from the findings and discussion sections of included papers.Sixteen peer-reviewed studies were included in the systematic review. Four major themes were revealed: Living with fear, stigma, and anxiety; Feelings of vulnerability, distrust, and discrimination; Dealing with past and present ways of life after resettlement; and Seeking support and involvement in health care.The findings suggest that future actions for improving maternity care quality should be focused on woman-centered practice, demonstrating cultural safety and developing mutual trust between a woman and her care providers. Meaningful consultation with women affected by FGM in high-income settings requires cultural sensitivity and acknowledgment of their specific circumstances. This can be achieved by engaging women affected by FGM in service design to provide quality care and ensure woman-focused policy is developed and implemented.
Turkmani, S, Homer, C, Varol, N & Dawson, A 2018, 'A survey of Australian midwives' knowledge, experience, and training needs in relation to female genital mutilation', Women and Birth, vol. 31, no. 1, pp. 25-30.View/Download from: UTS OPUS or Publisher's site
Female genital mutilation (FGM) involves partial or total removal of the external female genitalia or any other injury for non-medical reasons. Due to international migration patterns, health professionals in high income countries are increasingly caring for women with FGM. Few studies explored the knowledge and skills of midwives in high income countries.
To explore the knowledge, experience and needs of midwives in relation to the care of women with FGM.
An online self-administered descriptive survey was designed and advertised through the Australian College of Midwives' website.
Of the 198 midwives (24%) did not know the correct classification of FGM. Almost half of the respondents (48%) reported they had not received FGM training during their midwifery education. Midwives (8%) had been asked, or knew of others who had been asked to perform FGM in Australia. Many midwives were not clear about the law or health data related to FGM and were not aware of referral paths for affected women.
As frontline providers, midwives must have appropriate up-to-date clinical skills and knowledge to ensure they are able to provide women with FGM the care they need and deserve. Midwives have a critical role to play in the collection of FGM related data to assist with health service planning and to prevent FGM by working closely with women and communities they serve to educate and advocate for its abandonment. Therefore, addressing educational gaps and training needs are key strategies to deliver optimal quality of care.
Bartlett, L, LeFevre, A, Zimmerman, L, Saeedzai, SA, Turkmani, S, Zabih, W, Tappis, H, Becker, S, Winch, P, Koblinsky, M & Rahmanzai, AJ 2017, 'Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study', The Lancet Global Health, vol. 5, no. 5, pp. e545-e555.View/Download from: UTS OPUS or Publisher's site
Turkmani, S, Homer, C, Varol, N & Dawson, A 2017, 'A survey of Australian midwives' knowledge, experience, and training needs in relation to female genital mutilation', Women and Birth, vol. 30, no. Supplement 1, pp. 30-30.View/Download from: UTS OPUS or Publisher's site
Introduction: Female genital mutilation (FGM) involves partial or total removal of the external female genitalia or any other injury for non-medical reasons. Due to international migration patterns, health professionals in high-income countries are increasingly caring for women with FGM. Few studies have explored the knowledge and skills of midwives in high-income countries.
Aim: To explore the knowledge, experience and needs of midwives in relation to the care of women with FGM in Australia
Methods: An online self-administrated descriptive survey was designed and advertised through the Australian College of Midwives' website and e-bulletin to explore the perspectives of midwives regarding the care of women with FGM across states and territories of Australia.
Results: The survey revealed gaps in midwives knowledge of FGM. Of the 198 midwives (24%) did not know the correct classification of FGM. Almost half of the respondents (48%) reported they had not received FGM training during their midwifery education. Midwives (8%) had been asked, or knew of others who had been asked to perform FGM in Australia. Many midwives were not clear about the law or collecting FGM related health data and were not aware of referral paths for affected women.
Conclusion: As frontline providers, midwives must have appropriate up-to-date clinical skills and knowledge to ensure they are able to provide women with FGM the care they need and deserve. Midwives have a critical role to play in the collection of FGM related data to assist with health service planning and to prevent FGM by working closely with women, their partners and communities they serve to educate and advocate for its abandonment. Therefore, addressing educational gaps and training needs are key strategies to deliver optimal quality of care.
Foureur, M, Turkmani, S, Clack, DC, Davis, DL, Mollart, L, Leiser, B & Homer, CSE 2017, 'Caring for women wanting a vaginal birth after previous caesarean section: A qualitative study of the experiences of midwives and obstetricians.', Women and Birth, vol. 30, no. 1, pp. 3-8.View/Download from: UTS OPUS or Publisher's site
One of the greatest contributors to the overall caesarean section rate is elective repeat caesarean section.Decisions around mode of birth are often complex for women and influenced by the views of the doctors and midwives who care for and counsel women. Women may be more likely to choose a repeat elective caesarean section (CS) if their health care providers lack skills and confidence in supporting vaginal birth after caesarean section (VBAC).To explore the views and experiences of providers in caring for women considering VBAC, in particular the decision-making processes and the communication of risk and safety to women.A descriptive interpretive method was utilised. Four focus groups with doctors and midwives were conducted.The central themes were: 'developing trust', 'navigating the system' and 'optimising support'. The impact of past professional experiences; the critical importance of continuity of carer and positive relationships; the ability to weigh up risks versus benefits; and the language used were all important elements. The role of policy and guidelines on providing standardised care for women who had a previous CS was also highlighted.Midwives and doctors in this study were positively oriented towards assisting and supporting women to attempt a VBAC. Care providers considered that women who have experienced a prior CS need access to midwifery continuity of care with a focus on support, information-sharing and effective communication.
BACKGROUND: Strengthening midwifery is a global priority. Recently, global evidence has provided momentum toward developing the midwifery workforce. In 2014, the State of the World's Midwifery 2014 Report explored midwifery services in 73 low to middle income countries. In the South Pacific region, only Papua New Guinea and the Solomon Islands were included. This means that there is little known on the state of midwifery in the small island countries in the South Pacific. AIM: To explore the current situation of the education, regulation and association of midwives in 12 small island nations of the South Pacific and determine the gaps in these areas. METHODS: A descriptive study was undertaken. Data were collected through a survey completed by key representatives (usually the Chief Nursing and Midwifery Officer) from each of the 12 countries. Ethical approval was received from the relevant Human Research Ethics Committee. FINDINGS: Many of the countries had few midwives, in some instances, only two midwives for the whole country. Midwifery education programs included post-graduate diploma, certificates and bachelor degrees. Midwives were required to be registered nurses in all countries. Regulation and licensing also varied - most countries did not have a separate licensing system for midwives. Only three countries have a specific professional association for midwives. CONCLUSION: The variation and the small number of midwives poses challenges for workforce planning. Consideration could be given to developing regional standards and potentially a shared curriculum framework. Ongoing collaboration and networking between countries is a critical part of future developments.
Dawson, A, Varol, N, Turkmani, S, Hall, J & Black, K 2017, 'Evidence-based policy responses to strengthen health, community and legislative systems to care for women with female genital mutilation in Australia', Reproductive Health, vol. 14, no. 63, pp. 1-8.View/Download from: UTS OPUS or Publisher's site
Tappis, H, Koblinsky, M, Winch, PJ, Turkmani, S & Bartlett, L 2016, 'Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan', Global Public Health, vol. 11, no. 4, pp. 387-406.View/Download from: UTS OPUS or Publisher's site
Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.
Varol, N, Dawson, A, Turkmani, S, Hall, J, Nanayakkara, S, Jenkins, G, Homer, C & McGeechan, K 2016, 'Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006–2012: a descriptive study', BMC Pregnancy and Childbirth, vol. 16, no. 328, pp. 1-10.View/Download from: UTS OPUS or Publisher's site
Women, who have been subjected to female genital mutilation (FGM), can suffer serious and irreversible physical, psychological and psychosexual complications. They have more adverse obstetric outcomes as compared to women without FGM. Exploratory studies suggest radical change to abandonment of FGM by communities after migration to countries where FGM is not prevalent. Women who had been subjected to FGM as a child in their countries of origin, require specialised healthcare to reduce complications and further suffering. Our study compared obstetric outcomes in women with FGM to women without FGM who gave birth in a metropolitan Australian hospital with expertise in holistic FGM management.
The obstetric outcomes of one hundred and ninety-six women with FGM who gave birth between 2006 and 2012 at a metropolitan Australian hospital were analysed. Comparison was made with 8852 women without FGM who gave birth during the same time period. Data were extracted from a database specifically designed for women with FGM and managed by midwives specialised in care of these women, and a routine obstetric database, ObstetriX. The accuracy of data collection on FGM was determined by comparing these two databases. All women with FGM type 3 were deinfibulated antenatally or during labour. The outcome measures were (1) maternal: accuracy and grade of FGM classification, caesarean section, instrumental birth, episiotomy, genital tract trauma, postpartum blood loss of more than 500 ml; and (2) neonatal: low birth weight, admission to a special care nursery, stillbirth.
The prevalence of FGM in women who gave birth at the metropolitan hospital was 2 to 3 %. Women with FGM had similar obstetric outcomes to women without FGM, except for statistically significant higher risk of first and second degree perineal tears, and caesarean section. However, none of the caesarean sections were performed for FGM indications. The ObstetriX database was only 35 % accur...
Dawson, A, Homer, CS, Turkmani, S, Black, K & Varol, N 2015, 'A systematic review of doctors' experiences and needs to support the care of women with female genital mutilation.', International Journal of Gynecology and Obstetrics, vol. 131, no. 1, pp. 35-40.View/Download from: UTS OPUS or Publisher's site
BACKGROUND: Female genital mutilation (FGM) involves partial or complete removal of the external female genitalia or other injury for non-therapeutic reasons. Little is known about the knowledge and skills of doctors who care for affected women and their practice in relation to FGM. OBJECTIVES: To examine the FGM experiences and educational needs of doctors. SEARCH STRATEGY: A structured search of five bibliographic databases was undertaken to identify peer-reviewed research literature published in English between 2004 and 2014 using the keywords "female genital mutilation," "medical," "doctors," "education," and "training." SELECTION CRITERIA: Observational, quasi-experimental, and non-experimental descriptive studies were suitable for inclusion. DATA COLLECTION AND ANALYSIS: A narrative synthesis of the study findings was undertaken and themes were identified. MAIN RESULTS: Ten papers were included in the review, three of which were from low-income countries. The analysis identified three themes: knowledge and attitudes, FGM-related medical practices, and education and training. CONCLUSIONS: There is a need for improved education and training to build knowledge and skills, and to change attitudes concerning the medicalization of FGM and reinfibulation.
Dawson, A, Turkmani, S, Fray, S, Nanayakkara, S, Varol, N & Homer, C 2015, 'Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation: A review of global experience', Midwifery, vol. 31, no. 1, pp. 229-238.View/Download from: UTS OPUS or Publisher's site
to identify how midwives in low and middle income countries (LMIC) and high income countries (HIC) care for women with female genital mutilation (FGM), their perceived challenges and what professional development and workplace strategies might better support midwives to provide appropriate quality care.
an integrative review involving a narrative synthesis of the literature was undertaken to include peer reviewed research literature published between 2004 and 2014.
10 papers were included in the review, two from LMIC and eight from HIC. A lack of technical knowledge and limited cultural competency was identified, as well as socio-cultural challenges in the abandonment process of the practice, particularly in LMIC settings. Training in the area of FGM was limited. One study reported the outcomes of an education initiative that was found to be beneficial.
professional education and training, a working environment supported by guidelines and responsive policy and community education, are necessary to enable midwives to improve the care of women with FGM and advocate against the practice.
Implications for practice
improved opportunities for midwives to learn about FGM and receive advice and support, alongside opportunities for collaborative practice in contexts that enable the effective reporting of FGM to authorities, may be beneficial and require further investigation.
Dawson, AJ, Turkmani, S, Varol, N, Nanayakkara, S, Sullivan, E & Homer, CS 2015, 'Midwives' experiences of caring for women with female genital mutilation: Insights and ways forward for practice in Australia.', Women and Birth, vol. 28, no. 3, pp. 207-214.View/Download from: UTS OPUS or Publisher's site
Female genital mutilation (FGM) has serious health consequences, including adverse obstetric outcomes and significant physical, sexual and psychosocial complications for girls and women. Migration to Australia of women with FGM from high-prevalence countries requires relevant expertise to provide women and girls with FGM with specialised health care. Midwives, as the primary providers of women during pregnancy and childbirth, are critical to the provision of this high quality care.To provide insight into midwives' views of, and experiences working with, women affected by FGM.A descriptive qualitative study was undertaken using focus group discussions with midwives from four purposively selected antenatal clinics and birthing units in three hospitals in urban New South Wales. The transcripts were analysed thematically.Midwives demonstrated knowledge and recalled skills in caring for women with FGM. However, many lacked confidence in these areas. Participants expressed fear and a lack of experience caring for women with FGM. Midwives described practice issues, including the development of rapport with women, working with interpreters, misunderstandings about the culture of women, inexperience with associated clinical procedures and a lack of knowledge about FGM types and data collection.Midwives require education, training and supportive supervision to improve their skills and confidence when caring for women with FGM. Community outreach through improved antenatal and postnatal home visitation can improve the continuity of care provided to women with FGM.
Graham, H, Tokhi, M, Edward, A, Salehi, AS, Turkmani, S, Duke, T & Bartlett, L 2015, 'Use of clinical guidelines: perspectives from clinicians in paediatric and maternity hospitals in Kabul, Afghanistan.', Eastern Mediterranean Health Journal, vol. 21, no. 2, pp. 100-110.View/Download from: UTS OPUS or Publisher's site
This study explored the perceived value, role and reported use of clinical guidelines by clinicians in urban paediatric and maternity hospital settings, and the effect of current implementation strategies on clinician attitudes, knowledge and behaviour. A total of 63 clinicians from 7 paediatric and maternity hospitals in Kabul, Afghanistan participated in structured focus groups; content analysis methodology was used for identification and analysis of key themes. Seven sets of guidelines, protocols or standards were identified (including 5 WHO-endorsed guidelines). However, most are failing to achieve high levels of use. Factors associated with guideline use included: clinician involvement in guideline development; multidisciplinary training; demonstrable results; and positive clinician perceptions regarding guideline quality and contextual appropriateness. Implementation activities should fulfil 3 major objectives: promote guideline awareness and access; stimulate motivation among clinical guideline users; and actively facilitate adherence to guidelines.
Varol, N, Turkmani, S, Black, K, Hall, J & Dawson, A 2015, 'The role of men in abandonment of female genital mutilation: a systematic review', BMC Public Health, vol. 15, no. 1034.View/Download from: UTS OPUS or Publisher's site
Background: Men in their roles as fathers, husbands, community and religious leaders may play a pivotal part in
the continuation of female genital mutilation (FGM). However, the research on their views of FGM and their
potential role in its abandonment are not well described.
Methods: We undertook a systematic review of all publications between 2004 and 2014 that explored men's
attitudes, beliefs, and behaviours in regards to FGM, as well as their ideas about FGM prevention and
Results: We included twenty peer-reviewed articles from 15 countries in the analysis. Analysis revealed ambiguity
of men's wishes in regards to the continuation of FGM. Many men wished to abandon this practice because of the
physical and psychosexual complications to both women and men. Social obligation and the silent culture
between the sexes were posited as major obstacles for change. Support for abandonment was influenced by
notions of social obligation, religion, education, ethnicity, urban living, migration, and understanding of the
negative sequelae of FGM. The strongest influence was education.
Conclusion: The level of education of men was one of the most important indicators for men's support for
abandonment of FGM. Social obligation and the lack of dialogue between men and women were two key issues
that men acknowledged as barriers to abandonment. Advocacy by men and collaboration between men and
women's health and community programs may be important steps forward in the abandonment process.
Van Lerberghe, W, Matthews, Z, Achadi, E, Ancona, C, Campbell, J, Channon, A, de Bernis, L, De Brouwere, V, Fauveau, V, Fogstad, H, Koblinsky, M, Liljestrand, J, Mechbal, A, Murray, SF, Rathavay, T, Rehr, H, Richard, F, ten Hoope-Bender, P & Turkmani, S 2014, 'Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality.', Lancet, vol. 384, no. 9949, pp. 1215-1225.View/Download from: UTS OPUS or Publisher's site
This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of low-income and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education of midwives was only one element. Efforts in health system strengthening in these countries have been characterised by: expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of midwives, reduction of financial barriers, and late attention for improving the quality of care. Overmedicalisation and respectful woman-centred care have received little or no attention.
Zainullah, P, Ansari, N, Yari, K, Azimi, M, Turkmani, S, Azfar, P, LeFevre, A, Mungia, J, Gubin, R, Kim, Y-M & Bartlett, L 2014, 'Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program.', Midwifery, vol. 30, no. 10, pp. 1056-1062.View/Download from: UTS OPUS or Publisher's site
BACKGROUND: The shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010. OBJECTIVE: We analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned. DESIGN: We performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs. SETTING: For the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development. PARTICIPANTS: Midwives who had graduated from either IHS or CME schools. FINDINGS: CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9-66.6%) on the clinical competency assessment compared to 57.3% (49.9-64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,7...
Turkmani, S, Currie, S, Mungia, J, Assefi, N, Rahmanzai, AJ, Azfar, P & Bartlett, L 2013, ''Midwives are the backbone of our health system': Lessons from Afghanistan to guide expansion of midwifery in challenging settings', MIDWIFERY, vol. 29, no. 10, pp. 1166-1172.View/Download from: UTS OPUS or Publisher's site
Dawson, A, Turkmani, S, Varol, N, Sullivan, E & Homer, C 2015, 'Midwives' experiences of caring for women with female genital mutilation: Insights and ways forward for practice in Australia', Super Midwives - Making a Difference, Australian College of Midwives, 19th Biennial Conference, Gold Coast, Australia.View/Download from: UTS OPUS or Publisher's site
Dawson, A & Turkmani, S 2014, 'Evidence to inform education, training and supportive work environments for midwives involved in the care of women with female genital mutilation', Australian College of Midwives NSW Branch State Conference, Novotel Sydney Brighton Beach NSW.View/Download from: UTS OPUS
Female genital mutilation (FGM) is a practice that is carried out on young girls and women in 29 countries in Africa and the Middle East, as well as some Asian countries (WHO, 2008). Migration from these countries to Australia has led to an increasing number of midwives caring for women with FGM and educating families in order to prevent this harmful and illegal practice. However very little is known about the challenges midwives face in delivering care and education and what professional development and workplace strategies might better support midwives.
This presentation reports on a synthesis of the peer reviewed literature published between 2004 and 2014 undertaken to identify the knowledge, experiences and needs of midwives globally with respect to FGM. This review forms part of a larger research project funded by the Department of Health and Aging to examine the obstetric outcomes of women who have FGM and midwives experiences in Australia. Ten papers were included in the review, two from lower-middle income counties and eight from high income countries.
The findings indicate that midwives lack technical knowledge and cultural competency to adequately care for women. Midwives, particularly those in lower-middle income counties where FGM was traditionally practiced were found to face significant challenges in their efforts to advocate for the abandonment of the practice. Training for midwives in the area of FGM was limited. Only one study reported the outcomes of an education initiative that was found to be beneficial. Professional education and training, a working environment supported by guidelines and responsive policy and community education, were suggested are necessary to enable midwives to improve the care of women with FGM and advocate against the practice.
Implications for midwifery in NSW include the need for specialised education and training for midwives on FGM, alongside opportunities for collaborative practice in contexts that support the eff...