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Background Despite the many maternal healthcare policy programmes in Ghana such as free the antenatal care (ANC) and the fee-exemption policy under the National Health Insurance Scheme, among others, the country has yet to make substantial improvements in addressing low skilled care utilisation in pregnancy and delivery. From previous studies, maternal mortality has been linked to women’s healthcare decision-making power at the household level in many low and middle-income countries. Thus, a pregnant women’s ability to choose a healthcare provider, act on her preferences, and to be sufficiently financially empowered to take the lead in deciding on reproductive and pregnancy care has significant effects on service utilisation outcomes. Therefore, we explored rural community-level barriers to seeking care related to obstetric complications and delivery from the perspectives of mothers, youth, opinion leaders and healthcare providers in Nadowli-Kaleo and Daffiama-Bussie-Issa districts in the Upper West Region of Ghana. Methods This exploratory qualitative study was based on the narratives of women, health providers and community stakeholders regarding the expectant women’s autonomy to decide and utilise maternal care. To achieve maximal diversity of responses, purposive sampling procedures were followed in selecting 16 health professionals, three traditional birth attendants and 240 community members (opinion leaders, youth and non-pregnant women) who participated in individual depth interviews and focus group discussions. Results Women’s lack of autonomy to seek care without prior permission, perceived quality care of traditional birth attendants, stigmatisation of unplanned pregnancies and cultural beliefs associated with late disclosure of childbirth labour all delayed mothers timely use of skilled care in the study communities. These barriers compounded problems arising from communities that are geographically isolated from hospital care. Conclusions Decisions about seeking maternal care were usually made by the expectant woman’s husband and family without providing adequate support to pregnant women during the latter stages of pregnancy and delivery. We conclude that this is primarily a cultural issue . The study recommends a change in the approach to community-level health education campaigns for maximum impacts through the increased involvement of men and families in health service delivery and utilisation.

Background Over the years, governments and stakeholders have implemented various policies/programmes to improve maternal health outcomes in low-middle-income countries. In Ghana, Community Health Officers were trained as midwives to increase access to skilled maternal healthcare. The government subsequently banned traditional birth attendants from providing direct maternal healthcare in 2000. Despite these, there is an unprecedented utilisation of TBAs’ services, including herbal uterotonics. This has attempted to defeat stakeholders’ campaigns to improve maternal health outcomes. Thus, we explored and highlighted herbal uterotonic consumption in pregnancy and birth and the implications on maternal and newborn health outcomes in North-Western Ghana. Methods This was an exploratory qualitative study that investigated traditional birth attendants ( n  = 17) and healthcare providers' ( n  = 26) perspectives on the intake of herbal uterotonics in pregnancy and childbirth in rural Ghana, using in-depth interviews. A combination of convenience, purposive and snowball sampling procedures were employed in selecting participants. Results Findings were captured in two domains: (1) perceived rationale for herbal uterotonic intake, and (2) potential adverse impacts of herbal uterotonic intake in pregnancy and labour, and nine topics: (i) confidence in unskilled attendance at birth, (ii) cost and a shortage of essential medicines, (iii) herbal uterotonics as a remedy for obstetric problems, (iv) herbal uterotonics facilitate birth, (v) attraction of home birth for cultural reasons, (vi) affordability of herbal uterotonics, (vii) unintended consequences and adverse outcomes, (viii) risks using herbal uterotonics to manage fertility and (ix) risks using herbal uterotonics to facilitate home birth . Conclusion The findings have suggested that the intake of non-conventional herbal uterotonic is widespread in the study area, although the constituents of the herb are unknown. However, complex and multiple factors of healthcare cost, desire for homebirth, unawareness of the negative effects of such substances, perceived way of addressing obstetric problems and cultural undertones, among others, accounted for herbal uterotonics consumption. We also encourage research into the constituents of ‘mansugo’ and the potential benefits and adverse effects. We recommend qualitative studies involving previous users of this herbal uterotonic to inform policy and healthcare provision.

Background For over 25 years cord blood has been used as an alternative to bone marrow for therapeutic use in conditions of the blood, immune system and metabolic disorders. Parents can decide if they would like to privately store their infant’s cord blood for later use if needed or to publicly donate it. Parents need to be aware of the options that exist for their infant’s cord blood and have access to the relevant information to inform their choice. The aim of this paper is to identify parent’s knowledge and awareness of cord blood donation, private banking options and stem cell use, and parent sources and preferred sources of this information. Methods An integrative review was conducted using several electronic databases to identify papers on parents’ knowledge, attitudes and attitudes towards umbilical cord blood donation and banking. The CASP tool was used to determine validity and quality of the studies included in the review. Results The search of the international literature identified 25 papers which met review inclusion criteria. This integrative review identified parents’ knowledge of cord banking and/or donation as low, with awareness of cord blood banking options greater than knowledge. Parents were found to have positive attitudes towards cord blood donation including awareness of the value of cord blood and its uses, with the option considered to be an ethical and altruistic choice. Knowledge on cord blood use were mixed; many studies’ participants did not correctly identify uses. Information sources for parents on cord blood was found to be varied, fragmented and inconsistent. Health professionals were identified as the preferred source of information on cord blood banking for parents. Conclusions This integrative review has identified that further research should focus on identifying information that expectant parents require to assist them to make informed choices around cord blood banking; and identifying barriers present for health professionals providing evidence based information on cord blood use and banking options.

Background Parents today have several options for the management of their infant’s cord blood during the third stage of labour. Parents can choose to have their infant’s cord clamped early or to have deferred cord clamping. If the cord is clamped early, cord blood can be collected for private cord blood banking or public cord blood donation for use later if needed. If cord clamping is deferred, the placental blood physiologically transfuses to the neonate and there are physiological advantages to this. These benefits include a smoother cardiovascular transition and increased haemoglobin levels while not interfering with the practice of collecting cord blood for gases if needed. The aim of this study is to explore Australian maternity health professionals’ perspectives towards cord clamp timing, cord blood banking and cord blood donation. Methods Fourteen maternity health professionals (midwives and obstetricians) from both private and public practice settings in Australia participated in semi-structured interviews either in person or by telephone. Interviews were transcribed and data analysed using thematic analysis. Results Overall there was strong support for deferred cord clamping, and this was seen as important and routinely discussed with parents as part of antenatal care. However, support did not extend to the options of cord blood banking and donation and to routinely informing parents of these options even when these were available at their birthing location. Conclusion Formalised education for maternity health professionals is needed about the benefits and implications of cord blood banking and cord blood donation so that they have the confidence to openly discuss all options of cord clamp timing, cord blood banking and cord blood donation to facilitate informed decision-making by parents.

Background Nurses are at high risk of musculoskeletal disorders (MSDs). Although the prevalence of MSDs of the lower back, upper limbs, neck and shoulders have been reported previously in nursing, few studies have evaluated MSDs of the foot and ankle. This study evaluated the prevalence of foot and ankle MSDs in nurses and their relation to individual and workplace risk factors. Methods A self-administered survey incorporating the Nordic Musculoskeletal Questionnaire (NMQ) was distributed, over a nine-week period, to all eligible nurses (n = 416) working in a paediatric hospital in Brisbane, Australia. The prevalence of MSDs for each of the NMQ body regions was determined. Bivariate and multivariable logistic regression analyses were conducted to examine the relationships between activity-limiting foot/ankle MSDs and risk factors related to the individual (age, body mass index, number of existing foot conditions, smoking history, general physical health [SF36 Physical Component Scale], footwear features) or the workplace (level of nursing position, work location, average hours worked, hours worked in previous week, time since last break from work). Results A 73% response rate was achieved with 304 nurses completing surveys, of whom 276 were females (91%). Mean age of the nurses was 37 years (±10), younger than the state average of 43 years. Foot/ankle MSDs were the most prevalent conditions experienced by nurses during the preceding seven days (43.8%, 95% CI 38.2-49.4%), the second most prevalent MSDs to impair physical activity (16.7%, 95% CI 13.0-21.3%), and the third most prevalent MSD, after lower-back and neck problems, during the preceding 12 months (55.3%, 95% CI 49.6-60.7%). Of the nurse and work characteristics investigated, obesity, poor general physical health, existing foot conditions and working in the intensive care unit emerged as statistically significant (p < 0.05) independent risk factors for activity-limiting foot/ankle MSDs. Conclusions Foot/ankle MSDs are common in paediatric hospital nurses and resulted in physical activity limitations in one out of every six nurses. We recommend targeted education programs regarding the prevention, self-management and treatment strategies for foot/ankle MSDs. Further research is needed into the impact of work location and extended shift durations on foot/ankle MSDs.

Background Globally, the incidence of sleep-related infant mortality declined dramatically following the first public health campaigns seen internationally in the 1990s to reduce the risks of sudden infant death. However, Australian Sudden Unexpected Death in Infancy (SUDI) rates have plateaued with little change in incidence since 2004 despite two further public health safe sleep campaigns. This study aims to describe contemporary infant care practices employed by families related to the current public health SUDI prevention program. Methods A cross-sectional survey of 3341 Queensland primary caregivers with infants approximately 3-months of age was conducted using the Queensland Registry of Births, Deaths and Marriages as a sampling frame. Surveys were returned either via reply-paid mail or online. Questionnaires explored prevalence of infant care practices and awareness of safe sleep recommendations. Univariable analysis was used to generate descriptive statistics for key variables. Results Overall, only 13% of families routinely practised all six ‘Safe Sleeping’ program messages. More than one third (1118, 34%) of infants had slept in a non-supine sleep position at some time. Potentially hazardous sleep environments were common, with 38% of infants sleeping with soft items or bulky bedding, or on soft surfaces. Nearly half, for either day- or night-time sleeps, were routinely placed in a sleep environment that was not designed or recommended for safe infant sleep (i.e. a bouncer, pram, beanbag). Most babies (84%) were reportedly smoke free before and after birth. Sleeping in the same room as their caregiver for night-time sleeps was usual practice for 75% of babies. Half (1600, 50%) of all babies shared a sleep surface in the last two-weeks. At 8-weeks, 17% of infants were no longer receiving any breastmilk. Conclusions The prevalence rates of infant care practices among this Australian population demonstrate many families continue to employ suboptimal practices despite Australia’s current safe sleep campaign. Strategic approaches together with informed decisions about pertinent messages to feature within future public health campaigns and government policies are required so targeted support can be provided to families with young infants to aid the translation of safe sleep evidence into safe sleeping practices.

Despite being widely used, few studies have assessed the utility of the San Diego definition of sudden infant death syndrome (SIDS). The purpose of this study was to evaluate pathologists’ application of the San Diego definition in all cases of sudden unexpected death in infancy (SUDI) that occurred in Queensland, Australia, between 2010 and 2014. Key coronial documents of 228 cases of SUDI were reviewed independently by three reviewers and classified according to the San Diego definition. Clear guidance regarding the evidentiary threshold for classification and interpretation of the San Diego definition was provided. All reviewers classified cases identically in 202 cases (88.6%). Consensus was achieved on the classification of the remaining 26 deaths following case discussion. After review, 79 cases were classified as SIDS, a one third reduction compared with the original classification, mainly due to a high probability of accidental asphyxia. The number of cases classified as undetermined (USID) almost doubled (75/228, 32.9%), and there was more than a fivefold increase in cases classified as asphyxia (43/228, 18.9%). Natural conditions decreased by approximately one third (21/228, 9.2%). This study demonstrates that with clear guidelines for interpretation, the San Diego definition can be applied reliably, with discrepancies resolved through a process of peer review.

ObjectiveTo investigate primary infant caregiver awareness of the current national public health safe sleep messages and the associations of awareness with care practices.Design and settingA cross-sectional survey in Queensland, Australia. All families with live babies birthed during April–May 2017 were eligible. Questionnaires were distributed when infants were approximately 3 months old.ParticipantsOf the 10 200 eligible families, 3341 (33%) primary caregivers participated.Main outcome measuresParticipants were asked: to recall key safe sleeping messages they were aware of (unprompted); questions about their infant care practices; and to select the current, national six safe sleeping messages (prompted multi-choice).ResultsOverall, the majority of families are aware of sleep-related infant mortality and sudden infant death (3178/3317, 96%); however, approximately one in four caregivers (867/3292, 26%) could not identify the current six messages to promote safer infant sleep in a multi-choice question. Despite being aware of the six key messages, some caregiver practices did not always align with advice (336/2423, 14% were not smoke-free; 349/2423, 14% were not usually supine for sleep; 649/2339, 28% employed practices which may increase risk of head or face covering; 426/2423, 18% were not receiving breastmilk).ConclusionsThere is considerable scope for improvement in parent awareness and ability to recall key safe sleep messages. Awareness of advice does not always translate into safe infant care. Health promotion messaging to encourage safer infant sleep, ultimately aimed at reducing sudden unexpected infant deaths, needs more effective supportive strategies and dissemination if future campaigns are to be successful.

To investigate the under‐identification of Indigenous∗∗Due to repeated use throughout this paper the term Indigenous people will be respectfully used when referring to individuals who identify as Aboriginal and/or Torres Strait Islander. infants in death records and examine the impact of a multi‐stage algorithm on disparities in sudden unexpected deaths in infancy (SUDI). Data on SUDI in Queensland between 2010 and 2014 were linked to birth and death registrations, health data, and child protection and coronial records. An algorithm was applied to cases of SUDI and population data to derive Indigenous status. Numbers, proportions and rates of SUDI were compared. Using multiple sources of Indigenous status resulted in a 64.9% increase in the number of infants identified as Indigenous. The Indigenous SUDI rate increased by 54.3%, from 1.38 to 2.13 per 1,000 live births after applying the algorithm to SUDI and live births data. Applying an algorithm to both numerator and denominator data reduced numerator‐denominator incompatibility, to more accurately report rates of Indigenous SUDI and measure the gap in Indigenous infant mortality. Estimation of the true magnitude of the disparity is restricted by under‐identification of Indigenous status in death records. Data linkage improved the reporting of Indigenous infant mortality. Accuracy in reporting of measures is integral to determining genuine progress towards Closing the Gap.

Background In industrialised countries the incidence of postpartum haemorrhage (PPH) is increasing, for which exact etiology is not well understood. Studies have relied upon retrospective data with estimated blood loss as the primary outcome, known to be underestimated by clinicians. This study aimed to explore variables associated with PPH in a cohort of women birthing vaginally in coastal Queensland, Australia, using the gravimetric method to measure blood loss. Methods Women were prospectively recruited to participate using an opt-out consent process. Maternal demographics; pregnancy history; model of care; mode of birth; third stage management practices; antenatal, intrapartum and immediate postpartum complications; gravimetric and estimated blood loss; and haematological laboratory data, were collected via a pre-designed data collection instrument. Descriptive statistics were used for demographic, intrapartum and birthing practices. A General Linear Model was used for multivariate analysis to examine relationship between gravimetric blood loss and demographic, birthing practices and intrapartum variables. The primary outcome was a postpartum haemorrhage (blood loss > 500 ml). Results 522 singleton births were included in the analysis. Maternal mean age was 29 years; 58% were multiparous. Most participants received active (291, 55.7%) or modified active management of third stage (191, 36.6%). Of 451 births with valid gravimetric blood loss recorded, 35% ( n  = 159) recorded a loss of 500 ml or more and 111 (70%) of these were recorded as PPH. Gravimetric blood loss was strongly correlated with estimated blood loss ( r  = 0.88; p  < 0.001). On average, the estimated blood loss was lower than the gravimetric blood loss, about 78% of the measured value. High neonatal weight, perineal injury, complications during labour, separation of mother and baby, and observation of a gush of blood were associated with PPH. Nulliparity, labour induction and augmentation, syntocinon use were not associated with PPH. Conclusions In contrast to previous study findings, nulliparity, labour induction and augmentation were not associated with PPH. Estimation of blood loss was relatively accurate in comparison to gravimetric assessment; raising questions about routine gravimetric assessment of blood loss following uncomplicated births. Further research is required to investigate type and speed of blood loss associated with PPH.