University of Wollongong Research Online

University of Wollongong Thesis Collection 2017+ University of Wollongong Thesis Collections

2017

Prenatal nutrition: Exploring ’ role, knowledge and nutrition education

Jamila Mustafa Arrish University of Wollongong

Follow this and additional works at: https://ro.uow.edu.au/theses1

University of Wollongong Copyright Warning You may print or download ONE copy of this document for the purpose of your own research or study. The University does not authorise you to copy, communicate or otherwise make available electronically to any other person any copyright material contained on this site. You are reminded of the following: This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part of this work may be reproduced by any process, nor may any other exclusive right be exercised, without the permission of the author. Copyright owners are entitled to take legal action against persons who infringe their copyright. A reproduction of material that is protected by copyright may be a copyright infringement. A court may impose penalties and award damages in relation to offences and infringements relating to copyright material. Higher penalties may apply, and higher damages may be awarded, for offences and infringements involving the conversion of material into digital or electronic form. Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.

Recommended Citation Arrish, Jamila Mustafa, Prenatal nutrition: Exploring midwives’ role, knowledge and nutrition education, Doctor of Philosophy thesis, School of Health and Society, University of Wollongong, 2017. https://ro.uow.edu.au/theses1/145

Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library: [email protected] UNIVERSITY OF WOLLONGONG AUSTRALIA

Prenatal nutrition: Exploring midwives’ role, knowledge and nutrition education

This thesis is presented in fulfilment of the requirements for the Award of the Degree of Doctor of Philosophy from the University of Wollongong by

Jamila Mustafa Arrish

Bachelor of Public Health (Nutrition) Master of Public Health Master of Science (Nutrition and Dietetics)

School of Health and Society

2017

CERTIFICATION

I, Jamila Mustafa Arrish, declare that this thesis, submitted in fulfilment of the requirements for the award of Doctor of Philosophy in the School of Health and Society, University of Wollongong, is wholly my own work unless otherwise referenced or acknowledged. The document has not been submitted for qualifications at any other academic institution.

Jamila Mustafa Arrish 31 March 2017

ii

DEDICATION

To my parents, my husband and my brothers and sisters

iii

ABSTRACT

Background: Good nutrition during is considered one aspect of lifestyle that contributes to the health and wellbeing of the mother and the developing baby. In Australia and globally, most pregnant women enter pregnancy or obese and do not meet dietary recommendations. Pregnant women may not receive nutrition advice despite being perceived as receptive to nutrition messages. Midwives are ideally positioned to provide nutrition advice during pregnancy as they provide antenatal care to pregnant women. According to the International Confederation of Midwives core competencies, midwives are expected to have the knowledge and skills to assess maternal nutrition and provide nutrition advice accordingly. However, there has been limited literature, especially in Australia, about midwives’ role in this important area.

Aim: To explore the role of midwives in providing nutrition advice, their nutrition knowledge, the nutrition education the midwives receive during pre-registration education or during practice, and the nutrition education provided in programmes.

Research questions: The research addressed three main questions: what are Australian midwives’ knowledge of and attitudes towards nutrition during pregnancy and their confidence in providing nutrition advice and what education did they receive in nutrition pre and post registration? What are midwives’ perceptions of their role in providing nutrition advice? And how is nutrition positioned within midwifery programmes in Australia?

Theoretical framework: The study was underpinned by a conceptual framework based on a review of the literature. The central focus of the framework was exploring the factors influencing midwives’ behaviour of providing nutrition advice. The framework was a combination of the Knowledge-Attitude-Behaviour (KAB) model and other elements such as education, confidence, model of care, role perceptions, and barriers/facilitators.

Methods: The research was exploratory and descriptive with three linked phases. It included three studies using a mixed-methods approach incorporating both quantitative and qualitative methods. Phase one included a study that used an online survey sent to the members of the Australian College of Midwives (respondents: n = 329) to determine their received nutrition education, knowledge, attitudes, and confidence in the provision of nutrition advice during pregnancy. Phase two involved a study that was an in-depth exploration of Australian midwives’ perceptions of their role in discussing nutrition issues with pregnant women.

iv Semi-structured interviews were conducted with a sample of the members of the Australian College of Midwives who completed the online survey (respondents: n = 16). Phase three included a study that used a mixed-methods approach incorporating an online survey with 23 midwifery course coordinators (representing 24 Australian midwifery programmes) and telephone interviews conducted with seven of those coordinators to review how nutrition content was incorporated in midwifery education.

Findings: Several key findings were identified. In phase one, the majority of Australian midwives believed prenatal nutrition was ‘very important’ (86.6%) and that they had a ‘very significant’ role in educating women about it (75.7%) but most had substantial knowledge gaps and were not confident discussing nutrition with pregnant women. The majority of the midwives provided nutrition advice (93%). This advice was classified as ‘basic’ and ‘general’, and was focused on general topics. Only half of the midwives reported receiving nutrition education during their pre-registration education or during practice. When the education was described, midwives reported it as limited and lacking focus on key contemporary issues. Some midwives undertook personal initiatives to address this gap.

In phase two, midwives perceived their role in providing nutrition advice to pregnant women as a vital part of their practice but many barriers restricted the expansion and the efficacy of such a role. The accounts of many midwives revealed that their nutrition advice tended to be medically-oriented and not focused on wellbeing or health promotion.

In phase three, nutrition was taught within all midwifery programmes surveyed but was limited by low number of hours allocated (half of the programmes had only 5 to <10 hours for nutrition education) and its tendency to be problem-oriented and based on various assumptions. Collaboration with nutrition experts was lacking, as was the development of nutrition assessment skills or practical training for midwifery students in the provision of nutrition advice or support.

Discussion and Conclusion: Midwives provide regular care to pregnant women and have the opportunity to positively influence women’s and babies’ health by providing effective nutrition advice. However, the findings of this research indicated that midwives might not be adequately supported to do so. This research had not been undertaken previously in Australia. Three main recommendations emerged from the three phases of the research on the way nutrition could be integrated into midwifery curricula and practice in a manner that could help midwives deliver better nutrition education services to pregnant women in accordance

v with the women’s expectations of midwives’ expertise and professional role. It was evident from the findings of phase one that practising midwives need to be provided with continuing nutrition education; to increase their knowledge and confidence and improve their practice in providing nutrition advice and support to pregnant women. In order to reduce midwives over reliance on personal initiatives and improve their access to the latest evidence-based updates in term of nutrition, reliable and trusted sources, such as the Australian College of Midwives and midwives’ workplaces need to be actively involved in the provision of continuing nutrition education to midwives. Continuing nutrition education needs to be focused on general and specific nutrition topics as well as contemporary areas; to be in line with the advances in nutrition knowledge and the challenges faced by midwives in their practice.

Findings from phase two indicated the need for more reform in the provision of health care services, such as, involving more in antenatal care settings to provide resources and education for both pregnant women and the midwives.

Phase three highlighted the necessity of including nutrition knowledge and skills as core competency areas in Australian midwifery competency standards and involving food and nutrition experts in the development and provision of nutrition curricula in midwifery education. It also emphasised the need to include skills of nutrition assessment in midwifery nutrition curricula and provide opportunities for practical training for midwifery students. Improving the nutrition education of midwives is important as they are at the front line of providing health advice to pregnant women, which may not only impact on women’s health but also on their babies’ and families’ health in the short and long term.

vi PUBLICATIONS CONSTITUTING THIS THESIS

Peer-reviewed publications (appendices A–E)

Arrish, J., Yeatman, H. and Williamson M. (2014). "Midwives and nutrition education during pregnancy: A literature review." Women and Birth. 27(1): pp. 2–8.

Arrish, J., Yeatman, H. and Williamson M. (2016). "Australian midwives and provision of nutrition education during pregnancy: A cross sectional survey of nutrition knowledge, attitudes, and confidence." Women and Birth. 29(5): pp. 455–464.

Arrish, J., Yeatman, H. and Williamson M. (2016). "Nutrition education in Australian midwifery programmes: A mixed-methods study." Journal of Biomedical Education. 16:9680430, p. 12. DOI:10.1155/2016/9680430.

Arrish, J., Yeatman, H. and Williamson M. (2017). "Midwives’ role in providing nutrition advice during pregnancy – Meeting the challenges? A qualitative study." Nursing Research and Practice. 17:7698510, p 11. DOI:10.1155/2017/7698510.

Arrish, J., Yeatman, H. and Williamson M. (2017). "Self-reported nutrition education received by Australian midwives before and after registration." Journal of Pregnancy. 17:5289592, p.9. DOI:10.1155/2017/5289592.

vii Conferences arising from this thesis (appendices F-H)

Arrish, J., Yeatman, H. and Williamson M. (2012). "Nutrition education during pregnancy: What does the evidence show?." 4th Biennial Multidisciplinary Conference – Breathing New Life into maternity Care. Melbourne, Australia, 24–26 May 2012. Programme Book, pp. 26– 26. (Oral presentation)

Arrish, J., Yeatman, H. and Williamson M. (2014). " – What role for the ?." 30th International Confederation of Midwives. Prague, Czech Republic, 1–5 June 2014. (Symposium)

Arrish, J., Yeatman, H. and Williamson M. (2017). "Making a difference through professionalism: The need for evidence-based nutrition in midwifery education." 31st International Confederation of Midwives – Triennial Congress. Toronto, Canada, 18–22 June 2017. (Poster presentation)

viii MEDIA COVERAGE OF THESIS RELATED RESEARCH

Appendix I: Research invitation: Australian Midwifery News. (Winter 2012). "Exploring the role of midwives in nutrition education during pregnancy." The Australian College of Midwives 12(2): pp. 10–10.

Appendix J: Media release: "Study identifies key nutrition knowledge gaps in Australian midwives." University of Wollongong website, 11th November 2016. http://media.uow.edu.au/releases/UOW224251.html

Article: "Healthy mums, healthy bubs." The Stand website, University of Wollongong website, 11th November 2016. http://stand.uow.edu.au/healthy-mums-healthy-bubs/

Radio interview: ABC Illawarra Radio, 14th November 2016, Midwives and nutrition.

ix ACKNOWLEDGEMENTS

In the name of Allah, the Merciful, the Compassionate.

First and Foremost, praise is to Allah Almighty, the greatest of all, on whom ultimately I depend for sustenance and guidance. I would like to thank Allah Almighty for giving me the opportunity, determination and the strength to go on this journey. His continuous grace and mercy was with me throughout my life and ever more during the tenure of my research. My appreciation goes to many people and organisations that have supported and assisted me throughout the completion of this thesis.

I would like to express my deepest gratitude and special thanks to my supervisor Professor Heather Yeatman; you have been a tremendous mentor for me. I would like to thank you for your patience, motivation, and immense knowledge. Being under your supervision was a delightful experience. You were very approachable, very generous with your research knowledge and willing to help out in any situation. You showed me real compassion, sympathy and understanding during difficult times and responded flexibly to my changing needs. Thank you for encouraging my research and for allowing me to grow as a researcher, without your heartfelt support and guidance at all times it would not have been possible to conduct this research.

My sincere thanks also go to my co-supervisor Associate Professor, Moira Williamson, for providing invaluable guidance and feedback. Your unwavering support throughout the years has been priceless.

I express my appreciation for all the midwives and midwifery coordinators who completed the surveys and participated in the interviews. This research would not have been possible without their kind contribution.

I acknowledge the financial support provided by the Libyan Government and the Australian Government Research Training Programme Scholarship to undertake this research. This support has not only allowed me to pursue and finish my PhD but also to attend a number of courses and conferences.

Special thanks go to: Dr. Jo Russell and Associate Professor Marijka Batterham for providing statistical advice; the professional editor Elaine Newby for her valuable work and

x professional response; Ms. Cheryl Jecht for her assistance in transcribing the interviews, and Dr. Alexis St. George for her valuable feedback on my writing.

I would also like to thank all the staff at the School of Health and Society and the former School of Health Sciences for being so supportive throughout my PhD journey. I extend my thanks to all my fellow PhD students at the Faculty of Science, Medicine and Health, and the Faculty of Social Sciences for making this journey extra special through their support, encouragement and friendship.

To my dearest friend and my research soul mate! Khlood Bookari. I feel so privileged to have crossed the path of PhD with you, to have shared this journey with you, and to have gained what I believe to be a friendship for lifetime with you. You have been such a wonderful support to me and I will be thankful forever. Thank you for the laughter and happiness among the chaos and sadness and thank you for all great memories!

I am forever indebted to my beloved family members. Thank you to my late grandmother who always prayed for me, may Allah shower her soul with mercy. Thank you to my father and my mother, words cannot express how grateful I am for all the sacrifices that you have made on my behalf, your dreams for me have resulted in this achievement and without your loving upbringing and nurturing; I would not have been where I am today and what I am today. Thank you to all my brothers and sisters who have supported me in every possible way throughout my life. I am also thankful to my other family members and friends who have supported me along the way.

A big thank you goes to my beloved husband, Abdelrazeg Bashasha. Please accept my greatest thanks for having the greatest merit in fulfilling my dream – after Allah Almighty. For helping me walk that extra mile in my journey and supporting me throughout, and for always standing by my side during my ups and downs, I could not have done it without you. Thank you from the bottom of my heart.

xi TABLE OF CONTENTS

CERTIFICATION ...... ii DEDICATION ...... iii ABSTRACT ...... iv PUBLICATIONS CONSTITUTING THIS THESIS ...... vii MEDIA COVERAGE OF THESIS RELATED RESEARCH ...... ix ACKNOWLEDGEMENTS ...... x TABLE OF CONTENTS ...... xii LIST OF TABLES ...... xviii LIST OF FIGURES ...... xix LIST OF ABBREVIATIONS ...... xx 1 INTRODUCTION ...... 1 1.1 Background and the rationale of the study ...... 1 1.2 Aim ...... 2 1.3 Objectives of the research ...... 2 1.4 Research questions ...... 3 1.5 The significance of the research ...... 3 1.6 Antenatal care in Australia ...... 4 1.7 Midwifery models of care ...... 5 1.7.1 Midwifery Group Practice (MGP or Caseload midwifery) ...... 5 1.7.2 Team midwifery care ...... 5 1.7.3 Birth centre care ...... 6 1.8 Australian College of Midwives ...... 6 1.9 Midwifery education ...... 6 1.10 Outline of the thesis ...... 7 1.11 Summary ...... 9 2 LITERATURE REVIEW ...... 11 2.1 Preface ...... 11 2.2 Background ...... 13 2.2.1 The importance of nutrition during pregnancy and its impact on the health of the mother and the foetus ...... 13 2.2.2 Women’s nutrition knowledge, dietary behaviour during pregnancy, and reception of dietary advice from health care providers ...... 13

xii 2.2.3 Effect of nutrition interventions (including the provision of nutrition advice) on maternal and foetal outcomes ...... 14 2.2.4 Australian Dietary Guidelines and National Antenatal Care Guidelines ...... 16 2.3 The published literature: Midwives and nutrition education during pregnancy: A literature review ...... 18 2.3.1 Abstract ...... 18 2.3.2 Introduction ...... 19 2.3.3 Methods...... 21 2.3.4 Results and discussion ...... 22 2.3.5 Conclusion ...... 29 2.3.6 Acknowledgment ...... 30 2.4 Extended literature review ...... 31 2.4.1 Preface...... 31 2.4.2 Midwives and nutrition education during pregnancy including: nutrition knowledge and confidence ...... 31 2.4.3 Midwives as providers of nutrition information during pregnancy and their perceptions regarding their professional role in this area ...... 32 2.4.4 Sources of nutrition information ...... 33 2.4.5 Nutrition education during midwifery education and during practice ...... 33 2.4.6 Conclusion ...... 34 3 METHODOLOGY ...... 36 3.1 Preface ...... 36 3.2 Research approach...... 37 3.3 Philosophical assumptions ...... 37 3.4 Research design ...... 38 3.5 Conceptual framework ...... 41 3.6 Research methods ...... 43 3.7 The practitioners’ arm ...... 43 3.7.1 The quantitative study ...... 44 3.7.2 The qualitative study ...... 49 3.8 The education providers’ arm ...... 51 3.8.1 The quantitative study ...... 51 3.8.2 The qualitative study ...... 52 3.9 Ethical considerations ...... 53 xiii 3.9.1 Informed consent ...... 53 3.9.2 Confidentiality ...... 54 3.9.3 Anonymity ...... 54 3.9.4 Ethical approval ...... 55 3.10 Summary ...... 55 4 AUSTRALIAN MIDWIVES AND PROVISION OF NUTRITION EDUCATION DURING PREGNANCY: A CROSS SECTIONAL SURVEY OF NUTRITION KNOWLEDGE, ATTITUDES, AND CONFIDENCE ...... 56 4.1 Preface ...... 56 4.2 Abstract ...... 58 4.3 Summary of relevance ...... 59 4.4 Introduction ...... 60 4.5 Methods ...... 61 4.5.1 Design ...... 61 4.5.2 Research questions ...... 62 4.5.3 Sampling and administration ...... 62 4.5.4 Survey development...... 62 4.5.5 Survey structure ...... 63 4.5.6 Data analysis ...... 64 4.5.7 Ethical approval ...... 65 4.6 Findings ...... 65 4.6.1 Demographic characteristics ...... 65 4.6.2 Attitudes of midwives towards the importance of nutrition and their role in providing nutrition education during pregnancy...... 66 4.6.3 The provision of nutrition related advice by midwives and their confidence in discussing general and specific nutrition related issues ...... 66 4.6.4 Pregnancy general nutrition knowledge...... 70 4.6.5 Nutrition education ...... 72 4.6.6 Confidence in providing general and specific nutrition related advice ...... 72 4.6.7 Availability of dietitians’ services and referral to dietitians ...... 72 4.7 Discussion ...... 73 4.7.1 Limitations ...... 81 4.7.2 Future research ...... 82 4.8 Conclusion and practical implications ...... 82 xiv

4.9 Conflict of interest ...... 82 4.10 Acknowledgments and disclosures ...... 82 5 SELF REPORTED NUTRITION EDUCATION RECEIVED BY AUSTRALIAN MIDWIVES BEFORE AND AFTER REGISTRATION ...... 83 5.1 Preface ...... 83 5.2 Abstract ...... 84 5.3 Introduction ...... 85 5.4 Methods ...... 86 5.4.1 Design ...... 86 5.4.2 Participants and distribution ...... 86 5.4.3 Survey development...... 86 5.4.4 Survey items...... 87 5.4.5 Analysis...... 87 5.4.6 Ethical approval ...... 87 5.5 Results ...... 88 5.6 Discussion ...... 94 5.6.1 Limitations and strengths ...... 98 5.6.2 Practical implications ...... 99 5.6.3 Future research ...... 99 5.7 Conclusion ...... 99 5.8 Disclosure ...... 99 5.9 Conflict of interest ...... 99 5.10 Acknowledgment ...... 100 6 MIDWIVES’ ROLE IN PROVIDING NUTRITION ADVICE DURING PREGNANCY – MEETING THE CHALLENGES? A QUALITATIVE STUDY ...... 101 6.1 Preface ...... 101 6.2 Abstract ...... 102 6.3 Introduction ...... 103 6.4 Methods ...... 104 6.4.1 Design ...... 104 6.4.2 Sampling and participants ...... 104 6.4.3 Recruitment ...... 104 6.4.4 Data collection ...... 105 6.4.5 Data analysis ...... 106 xv

6.4.6 Ethical considerations ...... 107 6.5 Findings ...... 107 6.5.1 Participants ...... 107 6.5.2 Perceptions of midwives’ role in providing nutrition advice...... 108 6.5.3 Effect of model of care on the provision of nutrition advice ...... 109 6.5.4 Preparation to provide nutrition advice ...... 113 6.5.5 Barriers midwives encounter in the provision of nutrition advice ...... 116 6.5.6 Facilitators that would help midwives provide better nutrition advice ...... 119 6.6 Discussion ...... 121 6.6.1 Limitations and strengths ...... 123 6.6.2 Future research ...... 124 6.7 Conclusion ...... 124 6.8 Conflicts of interest ...... 124 6.9 Acknowledgment ...... 124 7 NUTRITION EDUCATION IN AUSTRALIAN MIDWIFERY PROGRAMMES: A MIXED-METHODS STUDY ...... 125 7.1 Preface ...... 125 7.2 Abstract ...... 126 7.3 Introduction ...... 127 7.4 Methodology ...... 129 7.4.1 Study design ...... 129 7.4.2 Stage 1: The survey ...... 129 7.4.3 Stage 2: The interview ...... 131 7.4.4 Ethical considerations ...... 133 7.5 Results ...... 133 7.5.1 Stage 1 ...... 133 7.5.2 Stage 2 ...... 137 7.6 Discussion ...... 143 7.6.1 Limitations and strengths ...... 148 7.6.2 Future research ...... 149 7.6.3 Implications for midwifery education ...... 149 7.7 Conclusion ...... 149 7.8 Competing interests ...... 150 7.9 Acknowledgements ...... 150 xvi

8 OVERALL DISCUSSION AND CONCLUSION ...... 151 8.1 Preface ...... 151 8.2 Introduction ...... 151 8.3 Summary and integration of the findings ...... 153 8.4 Significance of the research ...... 155 8.5 Contribution to knowledge ...... 156 8.6 Limitations and strengths ...... 157 8.7 Conclusions, recommendations, and future research ...... 162 8.7.1 Conclusions ...... 162 8.7.2 Recommendations ...... 163 8.7.3 Future research ...... 164 REFERENCES ...... 166 APPENDICES ...... 182

xvii

LIST OF TABLES

Table 2.1: Summary of the studies included in the review ...... 27 Table 2.2: Shows the governmental documents included in this review ...... 28 Table 4.1: Characteristics of the respondents ...... 67 Table 4.2: Attitudes of midwives towards the importance of nutrition and their role in providing nutrition education during pregnancy...... 68 Table 4.3: Provision of nutrition related-advice to pregnant women by midwives in the study and the availability of dietitians’ services and conditions for referral ...... 69 Table 4.4: The distribution of correct and incorrect/do not know answers of the knowledge questions (single-answer items and multiple-answer items) ...... 74 Table 4.5: Level of confidence of midwives in providing general and specific nutrition- related advice to pregnant women ...... 75 Table 5.1: Characteristics of the respondents ...... 89 Table 5.2: Nutrition information/education details ...... 91 Table 6.1: Midwives’ specified models of care ...... 108 Table 7.1: Overview of the respondents and included programmes ...... 134 Table 7.2: Topics covered in midwifery programmes of general nutrition/nutrition during pregnancy ...... 137

xviii

LIST OF FIGURES

Figure 1.1: A diagram illustrating the thesis outline where areas highlighted in green are published articles ...... 10 Figure 2.1: Flowchart for identifying eligible studies ...... 21 Figure 3.1: A diagram of the mixed-methods design of the overall thesis ...... 39 Figure 3.2 : The conceptual framework underpinning this research ...... 43 Figure 7.1: Hours allocated to general nutrition and/or nutrition during pregnancy in midwifery curricula by programme type ...... 135

xix

LIST OF ABBREVIATIONS

Abbreviation Full name

ACM Australian College of Midwives ANMAC Australian Nursing and Midwifery Accreditation Council ANMC Australian Nursing and Midwifery Council BMI GWG HREC Human Research Ethics Committee ICM International Confederation of Midwives KAB Knowledge-Attitude-Behaviour model MGP Midwifery Group Practice MW Midwife NHMRC National Health and Medical Research Council NICE National Institute for Health and Clinical Excellence (currently known as the National Institute for Health and Care Excellence) NMBA Nursing and Midwifery Board of Australia NSW New South Wales SDL Self-Directed Learning TDF Theoretical Domain Framework

xx

1 INTRODUCTION

1.1 Background and the rationale of the study Good nutrition during pregnancy is considered one aspect of lifestyle that contributes to the health and wellbeing of the mother and the developing baby. Pregnant women are recommended to consume a variety of nutritious food to meet increased nutrition requirements except for some nutrients, such as folic acid, iodine and iron, where supplementation might be needed (National Health and Medical Research Council 2013, Australian Health Ministers’ Advisory Council 2014). Adequate intake of folic acid supplement pre-conception and in the first trimester, for example, can reduce the risk of neural tube defects (Australian Health Ministers’ Advisory Council 2012). Adequate nutrition before and during pregnancy can reduce gestational weight gain (GWG) and may have the potential to reduce the incidence of pregnancy complications, such as the need for caesarean delivery, neonatal respiratory morbidity, and macrosomia especially in obese and overweight women (Muktabhant et al. 2015). It may also reduce the risk of pre-eclampsia (Muktabhant et al. 2015).

Poor dietary intake during pregnancy, on the other hand, has been linked to maternal excess weight gain as well as poor birth and foetal outcomes. Excess weight gain before or during pregnancy is associated with an increased risk of several complications, including: gestational , pregnancy-induced and pre-eclampsia (Marchi et al. 2015). Obese pregnant women are more likely to experience complicated labour, a caesarean delivery or preterm birth, and their babies are more likely to be large-for-gestational-age, have congenital defects, and be prone to perinatal death (Marchi et al. 2015). It has also been reported that overweight and obese women are less likely to breastfeed than women within the normal weight range (Marchi et al. 2015).

Pregnancy represents an opportune time to improve women’s dietary behaviour as they are usually interested in receiving nutrition information (Wilkinson and Tolcher 2010) and are motivated to change their behaviour for the sake of their babies (Szwajcer et al. 2005). However, pregnant women or women planning pregnancy often do not consume a balanced , despite the importance of nutrition during pregnancy. Australian women have been reported to be consuming less than their recommended amounts of nutrients needed during pregnancy (Hure et al. 2009). Poor intake of vegetable and fruits and high consumption of

1 fast food and soft drinks have also been documented among pregnant women (Wen et al. 2010).

Midwives in Australia are the health care providers who have most contact with pregnant women, especially those with uncomplicated , and therefore are in a unique to provide nutrition advice. However, the role of midwives in this important area has been neglected. A few international studies have indicated positive attitudes of midwives towards the importance of prenatal nutrition and their role in educating women about it (Mulliner et al. 1995, Elias and Green 2007). Yet midwives’ knowledge has been found to be poor (Mulliner et al. 1995, Barrowclough and Ford 2001) and they have not received adequate formal nutrition education pre or post registration as midwives (Mulliner et al. 1995). In addition, midwives have been found to not be confident discussing nutrition with pregnant women, especially in certain areas (Mulliner et al. 1995, Elias and Green 2007).

Midwives’ poor knowledge and their low confidence in discussing nutrition with pregnant women are not surprising as they have not received adequate nutrition education (Mulliner et al. 1995). Midwives need sufficient nutrition education in order to have the knowledge and the confidence necessary to discuss nutrition-related issues with pregnant women. However, how midwifery courses prepare midwives to provide nutrition advice to pregnant women and what knowledge and skills are taught about nutrition is an area that has also received little attention. If midwives are expected to discuss nutrition related-issues with pregnant women, these gaps need to be identified.

1.2 Aim The aim of this research was to explore the role of midwives in providing nutrition advice, their nutrition knowledge, the nutrition education they received before and after registration, and the nutrition education provided in midwifery programmes.

1.3 Objectives of the research The specific objectives of the research reported in this thesis were:

1. To determine the level of nutrition knowledge and attitudes of Australian midwives and their confidence in providing nutrition education during pregnancy.

2. To investigate the nutrition education received by practising midwives.

3. To explore midwives’ understanding and perceptions of their roles in nutrition education.

2 4. To review the nutrition content of curricula in midwifery programmes around Australia.

5. To provide recommendations from phase 1, 2, 3 and 4 to improve the provision of nutrition education in Australian midwifery programmes and to assist midwives to integrate nutrition education into their practice.

1.4 Research questions The thesis attempted to answer these specific questions, grouped as follows:

1. Midwives’ knowledge of and attitudes towards nutrition during pregnancy and their confidence in providing nutrition advice: What do midwives know about the role of nutrition during pregnancy? What are midwives’ attitudes towards the importance of nutrition during pregnancy and the significance of their role in providing nutrition advice? What are midwives’ confidence levels in providing general and specific nutrition advice?

2. Midwives’ education in nutrition: What nutrition education do practising midwives receive during their pre-registration education or while practising? What nutrition topics are included in the received education? Who provides such education?

3. Midwives’ perceptions of their role in providing nutrition advice: What are the perceptions of midwives regarding their professional role in providing nutrition advice during pregnancy? How does the model of midwifery care affect midwives’ provision of nutrition advice? What are the barriers/factors that midwives consider act to hinder or facilitate inclusion of nutrition education in their professional roles?

4. Nutrition in midwifery programmes in Australia: What are the food and nutrition content and skills being taught in midwifery programmes in Australia? How many hours are allocated to nutrition content within the curricula? Who is responsible for teaching and reviewing the nutrition content? What are the views of the course coordinators of the nutrition education within their programmes and the midwife’s role in providing nutrition advice?

5. How can nutrition curricula in Australian midwifery programmes be improved?

6. How can midwives be assisted to integrate nutrition education into their practice?

1.5 The significance of the research Prenatal nutrition is very important to the health of mothers and babies in the short and long term. Midwives are in an ideal position to provide nutrition advice to pregnant women.

3 Identifying any gaps in midwives’ knowledge and confidence will direct future interventions to address these gaps so midwives can be supported in providing accurate and adequate nutrition advice to pregnant women.

Understanding how midwives perceive their role in providing nutrition advice is fundamental, as is exploring the barriers and facilitators that can hinder or assist them provide effective nutrition advice. Knowledge of the role of the midwife would help create greater understanding of the nutritional role they can perform within the context of the care they provide, without burdening them with high expectations that perhaps they can not meet; or it may help overcome the barriers limiting their role and implement the facilitators that will expand their involvement in this area or make it more effective.

The perspectives of the midwives on the nutrition education they received during their pre- registration education and during practice and their views and justification for requiring further education will provide an important basis to improve the adequacy of the education in preparing midwives to discuss nutrition issues with women during pregnancy. Improving the nutrition education of midwives also requires understanding of the nutrition content of midwifery programmes and the perspectives of course coordinators regarding midwives’ nutrition education role and how nutrition content is positioned within the midwifery curricula.

The findings of this research may have direct implications for midwifery education in Australia. It will help inform the policy and provide recommendations regarding the way in which nutrition could be integrated in midwifery curricula and practice. It will have implications for the accreditation of midwifery education programmes in Australia. The ultimate aim is to help midwives deliver better nutrition advice to pregnant women in accordance with their expertise and professional role, so as to result in positive impacts on the health of mothers and their children.

1.6 Antenatal care in Australia Maternity care in Australia starts from conception until 6 weeks after birth. It includes: antenatal, intrapartum and postnatal care. Antenatal care is a type of routine maternity care provided to women during pregnancy. Antenatal care is usually provided by a range of health care providers including: midwives, General Practitioners (GPs), and Obstetricians. Midwives and GPs provide primary antenatal care for women with uncomplicated pregnancies while secondary and tertiary care for women with identified risks or

4 complications are usually provided by Obstetricians with the assistance of other medical professionals and midwives (Australian Health Ministers' Advisory Council 2008). The care provided in pregnancy offers a range of services comprising: ‘providing support and information, undertaking regular clinical assessments, screening for a range of infections and abnormalities, and offering social and lifestyle advice’ (Australian Health Ministers’ Advisory Council 2012 p. xviii). In Australia, antenatal care is provided in both public and private settings. Generally, women have four options for models of care: shared care, public midwifery models of care, private obstetric care, and private midwifery care. Shared care is a care that is shared between GPs and the hospital midwives and doctors. Labour, birth and after birth care is usually provided by the hospital midwives and nurses. Private midwifery care is a model of care where the care is provided by one midwife for the pregnancy, and for birth and postnatal care. If the midwife works in a group practice, the other midwives may provide back-up care. In this model, the midwife is employed by the women and not by a hospital. Women can choose who this midwife will be. In a private midwifery model, the women can choose to give birth at home or in hospital.

1.7 Midwifery models of care Midwifery models of care are where a midwife is the main person providing the care. In these models, the same midwife or group of midwives provides the care. Midwifery models of care available in Australia can be described as follows:

1.7.1 Midwifery Group Practice (MGP or Caseload midwifery)

In this model, the care is usually provided by one midwife throughout the pregnancy, labour and birth, and sometimes after birth. This is known as continuity of care. If the midwife is absent, a back-up midwife will be available.

1.7.2 Team midwifery care

Team midwifery care is similar to Midwifery Group Practice. However, instead of having one midwife caring for the pregnant women, a team of up to eight midwives will be available for care during pregnancy, labour, birth, and after birth.

5 1.7.3 Birth centre care

Birth centre care is when the care is provided by one midwife or a team of midwives and birth occurs in a birth centre. Therefore, during pregnancy, labour, and birth, women can either have a team midwifery or midwifery group practice model of care.

1.8 Australian College of Midwives The Australian College of Midwives (ACM) is the peak professional body for the midwifery profession in Australia. It is a national, non-profit organisation that was founded on the national level in 1984 after the associations at the states and territories levels united (Australian College of Midwives 2017). The organisation provides professional support for Australian midwives and sets the standards for both education and practice (Australian College of Midwives 2017). At the time of the study, the organisation had 4770 members from all Australian states and territories.

1.9 Midwifery education Midwifery education in Australia was until comparatively recently mostly hospital-based, with an apprenticeship-style model which usually lasted for three or more years (Australian Government Department of Health 2013). Prior to 2000, midwifery tertiary education was only a post graduate degree for registered nurses. In 2000, undergraduate midwifery degrees were introduced to Australia (Australian Government Department of Health 2013). Currently, there are three pathways for Australian midwives to be educated and registered. These are direct entry midwifery (Bachelor of Midwifery), double degree (Bachelor of Nursing/Bachelor of Midwifery), or postgraduate degree in midwifery subsequent to a nursing degree (Graduate Diploma and Masters level) (Australian Government Department of Health 2013).

The Australian Nursing and Midwifery Accreditation Council (ANMAC) is the body that directs Australian midwifery education (and was previously known as the Australian Nursing and Midwifery Council (ANMC)). The Council is responsible for accrediting midwifery programmes/degrees; and the Nursing and Midwifery Board of Australia (NMBA), the regulatory body of nursing and midwifery profession in Australia, is responsible for approving the accredited programmes/degrees (Australian Nursing and Midwifery Accreditation Council 2014). The Council sets the Standards of Accreditation (recently revised) (Australian Nursing and Midwifery Accreditation Council 2014). The Standards focus on continuity of care and clinical requirements as well as ensuring that students are able

6 to practise the full scope of midwifery practice on completion of the accredited midwifery programme and be eligible to apply for registration as a midwife (Australian Nursing and Midwifery Accreditation Council 2014). The Council sets also the National Competency Standards for the Midwife (Australian Nursing and Midwifery Council 2006) which education providers, registration authorities, and employers use to assess the midwife professional competency (Australian Nursing and Midwifery Accreditation Council 2014).

1.10 Outline of the thesis This thesis is presented as a thesis by compilation, including five published articles and other chapters. Each publication is presented in a separate chapter. Figure 1.1 shows the thesis outline.

Chapter 2 presents the literature review for this thesis. It consists of three parts. The first part presents background literature. The second part was published in the journal of Women and Birth in 2014. This published review explored research that had examined the role of midwives in nutrition education including: their nutrition knowledge, attitudes, and confidence in providing nutrition advice, and the sources they use to provide such advice. It also explored the literature around the nutrition content of midwifery programmes. The review identified gaps in the literature that constituted the main areas investigated in this thesis. The third part of the literature review contains information that was not covered in the published literature review due to constraints in publication. It also contains update of the research literature around similar areas that has been published since the publication of the original review and a discussion of the consistency of the updated literature with the initial literature review.

Chapter 3 presents the overall methodology of this thesis. It outlines the mixed-methods approach chosen to achieve the aim of the thesis and answer the research questions. It introduces pragmatism as the paradigm of the research. It also explains the convergent parallel research design, including the details of the two arms of the thesis: the practitioners’ arm (i.e. midwives) and the education providers’ arm (i.e. coordinators). The methods used in the research are detailed, including: the quantitative and qualitative studies, data collection, analysis, and ethical considerations. The conceptual framework of the thesis is also explained in the chapter. The conceptual framework focuses on exploring the variables/factors that may affect midwives’ behaviour of providing nutrition advice.

7 Chapter 4 addresses the first research question exploring what Australian midwives know about nutrition during pregnancy, their attitudes in regard to its importance, and their attitudes in regard to the significance of their role in providing nutrition advice, and their confidence in doing so. It presents the findings in those areas. Through the application of descriptive and inferential statistics about the association of midwives’ knowledge with demographic factors, it identifies the gaps in midwives’ knowledge and confidence that need to be addressed. It also reports on whether midwives received nutrition education during their midwifery education and during practice. Findings of this chapter have been published in the journal of Women and Birth.

Chapter 5 draws on data from Chapter 4 and addresses in greater detail the second research question, what nutrition education is received by practising midwives. It provides descriptive analyses for both qualitative and quantitative components. The chapter presents the midwives’ perceptions of the general characteristics of nutrition education they received during midwifery education and during practice, and discusses the gaps identified and the implications of such nutrition preparation on midwifery practice. This chapter has been published in the Journal of Pregnancy.

Chapter 6 presents an exploration of the perceptions of midwives regarding their role in providing nutrition advice during pregnancy. A qualitative descriptive approach was applied. Factors that midwives consider act to facilitate or hinder inclusion of nutrition education into their professional roles were identified. One interesting insight from this component of the research was how the model of care type affects the way midwives provide nutrition advice. This chapter has been published in the Journal of Nursing Research and Practice.

Chapter 7 reports the findings of the food and nutrition content in midwifery programmes in Australia from the perspectives of the course coordinators. A mixed-methods approach was applied, including an online survey and telephone interviews. Gaps in the current curricula were identified and suggestions are presented for future research and how midwifery education could improve the integration of nutrition content into the curricula. This chapter has been published in the Journal of Biomedical Education.

Chapter 8 comprises the overall discussion and conclusion of the thesis. It draws everything together providing a summary of the findings and discussing how the thesis answers the research questions. The chapter outlines the significance of the findings, contribution to the body of knowledge, and their limitations and strengths. It also outlines the overall conclusion

8

of the thesis and provides recommendations to guide policy and improve practice, together with suggestions for future research.

1.11 Summary This chapter introduced the thesis. It provided a brief background and the rationale for the research. It also identified the overall aim of the thesis, its objectives, the research questions, and its significance to midwifery practice and midwifery education. A snapshot was also given about antenatal care in Australia, midwifery models of care, the professional body of the midwifery profession (i.e. the Australian College of Midwives), and Australian midwifery education. The chapter ended by explaining the thesis outline. The next chapter will present the literature review that guided the current thesis.

9

Chapter 1: Introduction

Chapter 2: Literature review (3 parts) Part 1: Background Part 2: Published literature review: Midwives and nutrition education during pregnancy: A literature review Part 3: Extended literature review

Chapter 3: Methodology

Chapter 4: Published article

Australian midwives and provision of nutrition education during pregnancy: A cross-sectional survey of nutrition knowledge, attitudes, and confidence.

Chapter 5: Published article

Self-reported nutrition education received by Australian midwives before and after registration.

Chapter 6: Published article

Midwives’ role in providing nutrition advice during pregnancy – Meeting the challenges? A qualitative study.

Chapter 7: Published article

Nutrition education in Australian midwifery programmes: A mixed-methods study.

Chapter 8: Overall discussion and conclusion

Figure 1.1: A diagram illustrating the thesis outline where areas highlighted in green are published articles

10

2 LITERATURE REVIEW

2.1 Preface The recent interest in the effects of nutrition during pregnancy on the health of the mother and the baby can be traced back to the Barker hypothesis (Barker et al. 1989) which originated in the 1980s. This hypothesis proposed that adult have a foetal origin. Although it was considered controversial at the time, the hypothesis was established and supported by an accumulation of evidence. Research has also shown that the majority of pregnant women are motivated to change their dietary behaviour when becoming pregnant (Szwajcer et al. 2005). However, this motivation has not always translated to healthier diets (Hure et al. 2009). Some evidence suggests this lack of translation is a result of inadequate knowledge and lack of adequate support in this area from health professionals providing antenatal care (Begley 2002). Midwives are one of the established antenatal providers worldwide. Therefore, it is important to explore existing research that has reported on their role in this important area. This chapter presents a literature review of the knowledge and understanding of the midwife’s role in providing nutrition advice during pregnancy.

The chapter has three parts. The first part presents background literature. This includes information about: the importance of nutrition during pregnancy and its impact on the health of the mother and the foetus; women’s nutrition knowledge, dietary behaviour during pregnancy and reception of dietary advice from health care providers; the effect of nutrition interventions (including the provision of nutrition advice) on maternal and foetal outcomes and the official Australian guidelines containing diet related recommendations.

The second part presents a literature review that was published in 2014. The review deals mainly with the literature on the midwife’s role in nutrition education that had been reported prior to the commencement of the present research, that is, up to 2011. It identified studies that investigated the level of midwives’ nutrition knowledge, their thoughts about their role in this area, and how confident they felt discussing nutrition issues with women in their care. It also reported on what resources midwives used to support the advice they provided. Literature reporting on how nutrition is incorporated into midwifery curricula or within the standards of the profession was also included in the review. The review highlighted the gaps which forms the questions that this thesis sought to answer.

11

The third part of the chapter includes literature that was not included in the published review due to publications constraints or advances that have been reported in the period following commencement. In the next chapter, the overall methodology of the thesis is presented.

Note: The second part of this chapter has been written and published during the course of this degree in the peer-reviewed journal of Women and Birth (see Appendix A). The article is presented as it was published with minor modifications in terms of formatting (such as figure and table numbering, and the referencing style) to ensure cohesion within the thesis and to conform to the University of Wollongong’s referencing style which is the Author- Date. The Author-Date style is used throughout the thesis.

Citation: Arrish, J., Yeatman, H. and Williamson, M. (2014). "Midwives and nutrition education during pregnancy: A literature review." Women and Birth. 27(1): pp. 2–8.

Key findings of this part have also been presented by J. Arrish at the 4th Biennial Multidisciplinary Conference – Breathing New Life into Maternity Care in Melbourne in 2012 (see Appendix F).

Arrish, J., Yeatman, H. and Williamson M. (2012). "Nutrition education during pregnancy: What does the evidence show?." 4th Biennial Multidisciplinary Conference – Breathing New Life into Maternity Care. Melbourne, Australia, 24–26 May. Programme Book, 26–26 (oral presentation).

Authors’ contribution: J. Arrish conducted the literature review, analysed and interpreted the results, and wrote the manuscript. H. Yeatman and M. Williamson supervised the process and contributed to data interpretation and the development of the manuscript.

12 2.2 Background

2.2.1 The importance of nutrition during pregnancy and its impact on the health of the mother and the foetus

Evidence pointing to the importance of maternal nutrition during pregnancy for the health of the mother and the baby is increasing. A link between excess gestational weight gain and suboptimal nutrition during pregnancy has been reported (Uusitalo et al. 2009). Negative complications for the mother and the foetus have been connected with excess gestational weight gain and maternal . These include: increased risk of gestational diabetes, gestational hypertension, preeclampsia, , depression, and adverse effects on the ability of the woman to establish and maintain breastfeeding and her ability to lose weight postpartum. For the foetus, the risks include increased possibility of: still births and perinatal deaths, birth defects, neonatal care admission, macrosomia, childhood obesity, and chronic diseases in adulthood (Guelinckx et al. 2008, Langford et al. 2011, Marchi et al. 2015, Davies et al. 2016).

Conversely, during pregnancy has been associated with benefits for the health of the mother and the baby. Brantsæter et al (2014) summarised the results of 19 observational studies that investigated the association between maternal diet and pregnancy outcomes in 87,700 pregnant women using the same validated Food Frequency questionnaire. The authors identified that a healthy diet in line with official recommendations (consisting of regular intake of vegetables, fruit, , fish, and dairy, and lower intakes of sugar, sweetened beverages, processed meat, and salty snacks) was associated with better pregnancy outcomes, such as reduced gestational weight gain, and decreased risk of pregnancy complications, such as preterm birth, pre-eclampsia, and reduced foetal growth (Brantsæter et al. 2014).

2.2.2 Women’s nutrition knowledge, dietary behaviour during pregnancy, and reception of dietary advice from health care providers

Pregnant women’s dietary behaviour is a result of a complex interaction between intrapersonal factors (i.e. individual) and collective factors. Intrapersonal factors include: physiological factors (pre-pregnancy Body Mass Index (BMI), and nausea and vomiting), cognitive or perceptual factors (knowledge of nutrition requirements of pregnancy, perceptions of healthy eating in pregnancy, attitudes towards weight gain in pregnancy), and psychological factors (depression, stress, and emotional eating). Collective factors include: interpersonal factors (income, marital status/social support, and ethnicity), institutional

13

factors, community factors (food insecurity, location of stores and fast-food marketing), and public policy (Fowles and Fowles 2008). Nutrition knowledge is one of those numerous factors that may affect pregnant women’s diets (Fowles and Fowles 2008).

It has been established that pregnancy is an influential ‘teachable moment’ to promote healthy eating, as pregnant women are motivated to change their diet for the benefit of their babies (Phelan 2010). However, research continues to report low levels of nutrition knowledge among pregnant women where it is related to obesity and weight gain recommendations and their management (Shub et al. 2013, Bookari et al. 2016a), fruit and vegetables recommendations (de Jersey et al. 2013), and other areas related to nutrition during pregnancy (Bookari et al. 2016b, Lee et al. 2016). Moreover, research has repeatedly reported poor adherence to healthy eating recommendations among pregnant women (Hure et al. 2009, Blumfield et al. 2011, de Jersey et al. 2013, Malek et al. 2016, Bookari et al. 2017).

Some recent research has indicated a positive association between the reception of dietary advice from health care providers and pregnant women’s engagement in healthy dietary behaviour (May et al. 2014). However, pregnant women do not report receiving appropriate nutrition advice from health care providers (de Jersey et al. 2013). A recent systematic review including 31 studies of pregnant women and health care providers (including midwives) indicated that pregnant women in western countries (including Australia) may not be receiving adequate nutrition advice from their health care providers despite health providers acknowledging the importance of nutrition (Lucas et al. 2014a).

2.2.3 Effect of nutrition interventions (including the provision of nutrition advice) on maternal and foetal outcomes

Research has established the importance of nutrition during pregnancy for maternal and foetal health (Muktabhant et al. 2015), and at the same time has revealed an increasing number of pregnant women who enter pregnancy overweight and obese, or who gain weight in excess of the official recommendations (McIntyre et al. 2012). There has been an assumption that reducing weight gain and improving dietary behaviour of pregnant women would improve pregnancy and foetal outcomes (Thangaratinam 2015). Consequently, there has been an increased number of nutrition interventions (including nutrition education) during pregnancy (especially for overweight and obese women) in order to reduce the burden of maternal and childhood obesity and improve maternal and future generations’ health.

14

A number of researchers have assessed the benefits of diet and exercise interventions to reduce gestational weight gain and improve pregnancy outcomes. Thangaratinam et al (2012) conducted a systematic review and a meta-analysis including 44 randomised controlled trials with 7278 women and the interventions included diet, exercise, or a mixture of both. The authors concluded that dietary and lifestyle interventions were effective in reducing gestational weight gain and improving some pregnancy outcomes. Dietary interventions were found to be more successful in reducing weight gain compared to the other interventions. The rating of the evidence for reducing weight gain was moderate but was generally low for improving pregnancy outcomes. Similarly, a recent update of a Cochrane review by Muktabhant et al. (2015) which was first conducted in 2012 has found that interventions including diet or exercise or both were successful in reducing excess weight gain during pregnancy on average by 20%. The authors considered the evidence reviewed to be of high quality. There were very small reductions in a number of adverse pregnancy and foetal outcomes (evidence quality ranged from moderate to low), similar to the findings of Thangaratinam et al (2012). However, this may be due to methodological inconsistencies within the included trials (Flynn et al 2016).

One of the studies included in the systematic review by Muktabhant et al. (2015) was an Australian clinical trial conducted by Dodd et al (2014). These authors conducted a randomised controlled trial including 2212 women and found that lifestyle advice including dietary advice was effective in reducing above 4.5 kg, respiratory distress syndrome, and length of postnatal hospital stay for born to overweight or obese women (Dodd et al. 2014).

These reviews (Thangaratinam et al. 2012, Muktabhant et al. 2015) summarised that interventions during pregnancy, including dietary advice, are associated with reduced maternal weight gain in overweight and obese women, but the evidence is inconsistent on the effects of interventions on pregnancy outcomes. Nonetheless, any effectiveness of these interventions in reducing excess gestational weight gain (especially for normal weight and overweight women) is claimed to be worthwhile, as it would reduce weight retention in the and reduce the risk of obesity in subsequent pregnancies (Thangaratinam 2015). Researchers concluded that health care providers should continue to provide lifestyle and dietary advice according to current recommendations while research continues to be undertaken to obtain more robust evidence (Flynn et al 2016). This supports the involvement of health care providers (including midwives) in nutrition education roles as part of their 15 professional practice because of the potential benefits for the health of the mother and the baby.

2.2.4 Australian Dietary Guidelines and National Antenatal Care Guidelines

Nutrition advice provided by health care providers to pregnant women needs to be evidence- based. The main guidelines available in Australia to serve this object are the Australian Dietary Guidelines, which were revised during the study period (National Health and Medical Research Council 2013). These guidelines provide evidence-based healthy eating information that aims to promote the health and wellbeing of the population (including specific information for pregnant women) and reduce the risk of chronic conditions and diseases (National Health and Medical Research Council 2013). There were a few modifications in the revised version of the guidelines for pregnant women including: a change in the recommended number of serves for the five food groups (i.e. bread and cereals, meat and its alternatives, dairy, fruit, and vegetables) and a change in the standard serve size for the bread and cereals group (National Health and Medical Research Council 2013). However, the existence of guidelines alone is not enough, as Bookari and colleagues (2016b) found, with more than half of the Australian pregnant women in their study not being aware of the Australian Dietary Guidelines. The authors suggested that health care providers have a key role in increasing the awareness and knowledge of these guidelines among pregnant women.

In a significant move forward in relation to the role of health professionals in antenatal care, in 2012 the Australian Government released National clinical guidelines for antenatal care. These guidelines provide standard guidance for all antenatal care providers (including midwives) to promote consistency in the care provided. The guidelines had two modules. Australian National Antenatal Care Guidelines Module One was published in December 2012 (Australian Health Ministers’ Advisory Council 2012). Module One included advice on supplements and the management of nutrition-related issues, such as weight gain, nausea and vomiting. Module Two was published in 2014 (Australian Health Ministers’ Advisory Council 2014) and included advice on the provision of nutrition guidance to pregnant women (incorporating the Australian Dietary Guidelines) and encouraged discussion of women’s diets at every antenatal visit.

Other guidelines in Australia that also encourage providing nutrition advice to pregnant women at the first contact are the Standards of Maternity Care (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014) which have been revised

16 recently (2016) with no significant changes in its content in relation to the provision of nutrition advice. However, research shows that the mere existence of clinical guidelines as just described does not always translate into practice (Grol and Wensing 2004, Waller et al. 2016).

The next section presents the published literature review including: the abstract, introduction, methods, results and discussion, and conclusion.

17 2.3 The published literature: Midwives and nutrition education during pregnancy: A literature review

2.3.1 Abstract

Objectives: This review explored the extent to which the role of midwives in nutrition education during pregnancy has been reported in the literature, and areas requiring further research were identified.

Review method: A review of the literature was undertaken. Articles included in the review were published in English, in scholarly journals, and provided information about the knowledge, education, and attitudes of midwives towards nutrition during pregnancy.

Results and discussion: Few studies were identified. The included studies were exploratory and descriptive. Studies had reported that midwives lacked a basic knowledge of nutrition requirements during pregnancy. This might be attributed to inadequate nutrition education provided in both undergraduate and postgraduate midwifery programmes. The nutrition education components of midwifery courses were not identified within the studies reviewed.

Conclusion: Limited international or Australian research is available that reports on the role of midwives in nutrition education during pregnancy and the nutrition content of midwifery curricula. This represents an important omission in midwives capacity to support the health of pregnant women and their babies. More research is required to explore the educational needs of midwives to enhance nutritional care for pregnant women.

Keywords: Midwives; Nutrition; Education; Pregnancy; Pregnant women; Review.

18

2.3.2 Introduction

Healthy children are the foundation of a healthy population. For children to enjoy this good health, healthy practices and care should start during (or before) pregnancy (Pasinlioglu 2004). Good nutrition during pregnancy is one of the most significant components affecting both the health of the mother and the health and development of the foetus (Saravanan and Yajnik 2010). Poor quality diets during pregnancy have been found to be associated with maternal excess weight gain, pre-eclampsia, preterm birth, or even miscarriage (Williamson 2006). In addition, excess weight gain and imbalanced diet, particularly among obese women during pregnancy, have been identified as risk factors for abnormal glucose tolerance (Tovar et al. 2009).

Poor outcomes have also been linked with poor maternal nutrition. These include: inadequate development, low birth weight, and an increased risk of developing chronic diseases later in life (Wilkinson and Tolcher 2010). Adult diseases proposed to have a foetal origin (Barker et al. 1989, Barker et al. 1993a) and linked with nutrition during pregnancy include: cardiovascular diseases (Martyn 1994), diabetes (Barker et al. 1993b), and issues associated with bone mass formation (Jones et al. 2000). These claimed links between chronic illnesses and foetal and maternal influences have been subject to active debate but have been confirmed by more recent reviews and studies (Harding 2001, McMillen et al. 2008, Calkins and Devaskar 2011, Leach 2011, Yajnik and Deshmukh 2012).

Pregnant women show an increased awareness of nutrition status during their pregnancy. This has been attributed to their perception of the importance of nutrition as a change they can make in their everyday lives to protect the health of their babies (Szwajcer et al. 2005). In a study conducted in Australia, pregnant women were interested in receiving nutrition information during their pregnancy, especially information about healthy eating, , vegetarian diet, breastfeeding, morning sickness, and heart burn (Wilkinson and Tolcher 2010). The pregnancy period represents a life experience for a woman that can impact on her current health and that of her foetus and can also generate nutrition awareness that may affect her nutritional behaviour in the longer term (Szwajcer et al. 2007).

Women’s increased awareness of nutrition during the pregnancy period may not be capitalised on by health care providers. Research suggests that pregnant women might not be receiving nutrition advice from their health care professionals during pregnancy (Begley 2002). In a study conducted with 190 pregnant women in antenatal clinics within two

19

hospitals in New South Wales (NSW), Australian pregnant women reported a lack of knowledge of long-chain omega-3 polyunsaturated fatty acids, and they reported that their health care professionals did not provide them with adequate information on the importance of eating foods high in long-chain omega-3 polyunsaturated fatty acids during pregnancy (Sinikovic et al. 2008). In the same study, books and magazines were reported to be the women’s main source of information (Sinikovic et al. 2008). In part, this may reflect shortcomings that have been found in the materials made available to pregnant women in Australia (Begley 2002, Butler et al. 2008). Studies also have reported pregnant women’s ignorance of the availability of education materials (even when provided to them) if health professionals did not act to emphasise the nutrition messages within such materials (Szwajcer et al. 2009).

It has been established that nutrition education during pregnancy is associated with positive pregnancy outcomes (Garg and Kashyap 2006, Everette 2009, Streuling et al. 2010). Pregnant women report midwives as their trusted source of information and advice, as they perceive them to have the necessary expertise (Szwajcer et al. 2005, Szwajcer et al. 2009). This view of midwives influencing maternal and infant health outcomes through advice and care is reflective of the concepts of primary health care (Australian College of Midwives 2004). In this way, midwives should be considered to have an impact on the health of the community (Biro 2011).

The role of midwives in nutrition education during pregnancy is being increasingly recognised. In 2008, the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom issued recommendations for health professionals (including midwives) to provide women during pregnancy and pre-conception with nutrition support and advice (National Institute for Health and Clinical Excellence 2008). In Australia, the only available guidelines are the Healthy Eating Guidelines for Pregnant Women from the Department of Health and Ageing, which are general guidelines and do not inform health professionals, such as midwives (who are not trained in nutrition), on how to approach pregnant women in regard to nutrition advice (National Health and Medical Research Council 2013).

Midwives are in a prime position to provide healthy eating information to pregnant women (Biro 2011). However, Davis et al. (2012) identified in an Australian study evaluating an intervention programme for women with a Body Mass Index (BMI) greater than 35 that health professionals, including midwives, benefited from additional education to enable them

20 to provide healthy eating information. Little is known regarding the extent to which midwives fulfil their role in nutrition education. Thus, the aim of this literature review is to explore what has been investigated about the role of midwives in providing nutrition education during pregnancy.

2.3.3 Methods

2.3.3.1 Search strategy A review of the literature was undertaken to locate relevant studies in the areas of nutrition, pregnancy, education and the role of midwives.

The search started with identifying relevant journal articles. Governmental websites, such as the Australian Government Department of Health and Ageing, the Australian Nursing and Midwifery Council (ANMC) and the Australian College of Midwives (ACM), were also explored to identify any guidelines pertinent to the nutrition role of midwives during pregnancy (Figure 2.1).

Figure 2.1: Flowchart for identifying eligible studies

21

2.3.3.2 Databases searched The databases searched included: Thomson Reuters’ Web of Science, SCOPUS, Medline, CINAHL, Cochrane library, ScienceDirect, ProQuest Central and PubMed Central.

To ensure a broad body of literature, no date limits were applied. The only restrictions were that the articles were published in English, in scholarly journals and provided information about the knowledge, education, and attitudes of midwives towards nutrition during pregnancy.

Studies that dealt with the role of midwives in education regarding smoking, alcohol, and clinical aspects of nutritional issues (such as anaemia) were excluded.

2.3.3.3 Key words used to search for relevant literature A wide variety of key words were used across the searched databases. The key words included: health professional, midwife, nutrition, food, maternal nutrition, antenatal, prenatal, healthy eating, pregnancy, pregnant women, education, knowledge, practise, attitude, behaviour, importance, role, effect, recommendation, guidelines and approach.

Boolean operators and truncation between different search terms were used in accordance with the specific instructions of each database, either to broaden, narrow or refine the search results.

Additional strategies to enrich the search findings were applied, including use of synonyms and alternative key words, exchanging singular and plural and using spelling variations (for example; fetal, foetal).

The bibliographies and reference lists of the relevant articles were also examined to identify further studies.

2.3.4 Results and discussion

2.3.4.1 Overview of the studies In comparison to the number of studies investigating midwives’ knowledge of smoking (Thyrian et al. 2006), alcohol (Jones et al. 2011), and breastfeeding (Cantrill et al. 2003, Furber and Thomson 2008), few studies explored the nutrition knowledge and practices of midwives. Of those studies that have been undertaken to explore the knowledge, attitudes,

22

education and communications skills of midwives regarding nutrition in pregnancy (Mulliner et al. 1995, Barrowclough and Ford 2001, Elias and Green 2007, Wills and Forster 2008, Szwajcer et al. 2009, Bondarianzadeh et al. 2011, Schmied et al. 2011, Lee et al. 2010), the majority were descriptive and exploratory. Summary details of the studies are presented in Table 2.1. Governmental documents included in this review are also listed in Table 2.2.

2.3.4.2 Midwives and nutrition education during pregnancy Midwives were reported to lack the essential knowledge and skills to provide adequate or reliable nutrition advice (Mulliner et al. 1995, Barrowclough and Ford 2001), which may be somewhat contrary to the expectations of the women in their care (Bondarianzadeh et al. 2007). For example, a study by Mulliner and colleagues (1995) in the United Kingdom used both quantitative and qualitative approaches to explore the education, knowledge and attitudes to nutrition during pregnancy in a randomly selected sample of registered midwives (n = 77). They reported that 86% (50 of 77 participants) of registered midwives had no formal nutrition education post qualification; 46% (27 of 77 participants) scored poorly in nutrition knowledge; and more than half of those midwives (58 of 77 participants) felt unqualified to provide nutrition advice for pregnant women, especially to vegetarian women, women from ethnic or religious background or women with prior medical conditions. Although the authors acknowledged the small size of their sample, the study results clearly indicated that midwives lacked basic nutrition information and would benefit from improving their nutrition knowledge (Mulliner et al. 1995).

Another study in the United Kingdom by Barrowclough and Ford (2001) examined the knowledge of 35 midwives and reported that the midwives had poor knowledge in areas, such as recommended weight gain, recommended increase in energy requirements, women at risk of iron-deficiency anaemia and folic acid requirements during pregnancy; to prevent reoccurrence of Neural Tube Defect, and when should folic acid supplement be commenced.

A relatively recent study in New Zealand similarly examined midwives’ nutrition knowledge and their perceptions of the importance of nutrition during pregnancy (n = 370) (Elias and Green 2007). The study reported that less than 40% (n = 136/370) of midwives had formal nutrition education, of whom 75% (n = 106/136) had received nutrition information as a component of their midwifery education. The other sources of midwives’ nutrition education were not reported.

23 In contrast to the low levels of nutrition training, the New Zealand study found that the majority of midwives indicated that nutrition was ‘important’ or ‘very important’ during pregnancy and 94.9% of the midwives (n = 351/370) indicated they played a ‘significant’ or ‘very significant’ role in educating pregnant women about nutrition (Elias and Green 2007). The declaration of the majority of midwives in this study of being involved in educating pregnant women about nutrition but not having received nutrition information as a component of their professional training raises the question of their preparedness to provide such information. In addition, their perception that they played a significant/very significant role in nutrition education of pregnant women would benefit from further exploration, as it is unclear what roles they actually performed and what professional guidance was available to inform this role.

New Zealand midwives in general reported a high level of confidence in dealing with nutrition issues apart from providing advice to vegetarian women or women with medical conditions such as gestational diabetes. The study also identified the lack of guidelines about nutrition education for health professionals in Australia and New Zealand, and recommended that development of a policy regarding this matter should be considered in both countries.

The Australian Nursing and Midwifery Council (ANMC) in their national competency standards (Australian Nursing and Midwifery Council 2006) confirmed that the midwife has an important role in general health counselling and education, including antenatal education. A recent report on core competencies and an educational framework for primary maternity services in Australia further identified that the role of midwives included the promotion of healthy eating (Homer et al. 2010). The development of these core competencies involved a Delphi process with Australian midwives, indicating professional recognition of the nutrition education role of midwives.

Midwives’ lack of knowledge and essential skills regarding nutrition is not limited to Australia or the United Kingdom. This was confirmed in a study by Szwajcer and colleagues (2009) who undertook an in-depth exploration of verbal and written communication of midwifery practices in Holland. They reported that nutrition communication was provided relatively late in pregnancy, when pregnant women were more interested in other things related to pregnancy than in receiving nutrition education. Although pregnant women in the study were educated about healthy nutrition in general terms and were given nutrition

24

brochures by their midwives, the midwives did not reinforce the information in the brochures and therefore pregnant women rarely looked at them at home.

The study by Wills and Forster (2008) found that even when midwives offered nutritional advice for pregnant women, this advice lacked sound scientific evidence. For instance, in matters such as nausea and vomiting, it was found that herbal supplements and alternative therapies were usually included in the advice given, despite the lack of evidence-based guidelines to direct midwives’ practice in this area (Wills and Forster 2008). This may indicate a lack of appropriate education on nutrition during pregnancy and that midwives may not recognise the need for a sound scientific evidence base for their nutrition-related practice as for their other areas of professional practice.

Overall, the literature suggests that midwives would benefit from more nutrition education (Mulliner et al. 1995, Barrowclough and Ford 2001). Reflecting this situation, Barrowclough and Ford (2001) developed open learning materials for a sample of midwives in the United Kingdom (n = 35) to improve their nutrition knowledge. The scores of nutrition knowledge of the midwives in the study increased significantly after accessing and reviewing the materials (mean scores increased from 46.81 in the pre-questionnaire to 71.29 in the post-questionnaire p < 0.001). The authors recommended that for these programmes to be successful, policy makers and managers should allocate sufficient time for such education. Unfortunately, no research regarding further developments of this project was subsequently identified in the literature.

2.3.4.3 Sources of nutrition information obtained by midwives Limited research has been published that has examined the sources of nutrition information used by midwives. In a small study (n = 77) conducted in the United Kingdom, approximately half of the midwives (48%) reported they relied on the media (not specified) rather than their professional education as a key source from which to obtain nutrition information (Mulliner et al. 1995). This is in contrast to a relatively recent study in New Zealand that reported New Zealand midwives used mainly the Ministry of Health documents, such as the guidelines for pregnant and breastfeeding women and the New Zealand Food Safety Authority pamphlet on food safety, as their sources for nutrition information. The same study reported that only 53% (196 of 370) of midwives accessed other health professionals, such as dietitians, for information (Elias and Green 2007). This can possibly be explained by the fact that there was already a comprehensive and detailed publication about

25

the various nutritional issues during pregnancy and their management (including practical advice) available for midwives in New Zealand (Ministry of Health 2008).

The same cannot be said about other countries such as Australia, as there are currently no studies reporting on the sources and accuracy of nutrition information provided by Australian midwives to pregnant women. Preliminary investigations indicate that nutrition education resources available via antenatal clinics, where many midwives work, do not have a comprehensive coverage of nutrition issues important during pregnancy (Butler et al. 2008). Such a lack of nutrition guidance for midwives in Australia to direct their nutrition counselling practices for pregnant women might lead them to obtain their information from sources which might not be evidence-based or up to date. This would not only result in a missed nutrition education opportunity but also potentially result in health professionals mis- informing pregnant women (Wills and Forster 2008). Thus investigating this matter should be considered a public health priority.

2.3.4.4 Midwives as primary providers of nutrition information during pregnancy Nutritionists and dietitians are the professionals who are educated and accredited to provide dietary advice to the population, including pregnant women. A study of pregnant women in antenatal clinics in Queensland reported they preferred to have access to a as an expert in the field of nutrition, however few women have such access (Wilkinson and Tolcher 2010). It also is unlikely that pregnant women in Australia would consult a dietitian due to the limited number of dietitians available in maternity services (Wilkinson and Tolcher 2010). In some instances a woman may be referred to a dietitian by a general practitioner due to the pre-existence or emergence of a particular problem during pregnancy (The Royal Australian College of General Practitioners 2016).

It is more common for pregnant women, particularly those with a low risk pregnancy, to have contact with a midwife (Hatem et al. 2008). Hence, when they are the primary caregivers during pregnancy, midwives have the opportunity to provide nutrition advice to pregnant women in a timely manner. Midwives potentially may benefit from dietitians or nutritionists developing practice guidelines for midwives or formulating collaborative strategies regarding nutrition education (Elias and Green 2007).

26

Table 2.1: Summary of the studies included in the review

27

Table 2.2: Shows the governmental documents included in this review

Food and nutrition guidelines for healthy pregnant women-A background paper A ustralian Nursing and Midwifery Council Standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia—with evidence guide Australian College of Midwives , ACM Philosophy for Midwifery Australian Nursing and Midwifery Council National Competency Standards for the Midwife National Institute for Health and Clinical Excellence (NICE) Improving the nutrition of pregnant and breastfeeding mothers and children in low income households

The recently released National Maternity Services Plan (2011) (Australian Health Minister's Conference 2011) clearly emphasises the importance of equipping midwives (among other health professionals) with all the necessary knowledge and skills to provide better maternity services, including addressing the issue of obesity. This is essential if the goal of healthiest Australia is to be attained by 2020, as discussed by the National Preventive Health Taskforce in 2008 (Australian Government National Preventive Health Taskforce 2008).

2.3.4.5 Nutrition content of curricula in midwifery programmes Touger-Decker et al. (2001) suggested that nutritional issues and their management should be included in the education curricula of midwifery courses. Two studies were identified that had described how nutrition content is incorporated into subjects within midwifery programmes (Kolasa et al. 1997, Elias and Stewart 2005). The studies are examples from the United States and New Zealand about how nutrition can be easily integrated into midwifery education based on midwifery competencies. The United States example explained how a 2- hour seminar on nutrition during pregnancy assisted midwives to achieve competencies in nutrition assessment and counselling (Kolasa et al. 1997). The New Zealand example showed how collaboration between dietitians and midwifery educators can work to provide midwives with the best evidence-based nutrition knowledge. It included the stages of developing an optional nutrition paper using different models based on students’ feedback on what can help them to deliver better nutrition advice. What is promising is the students in the study suggested that this education needed to be compulsory. Registered midwives would also be offered the opportunity to benefit from the nutrition exercise (Elias and Stewart 2005).

There is a lack of data about what nutrition content is being taught in Australian midwifery programmes and whether nutritional assessment or management skills are required as a pre- registration competency for Australian midwives. In Australia, nutrition can be taught as a

28 part of the curricula in both undergraduate and postgraduate courses for midwives. However, no national strategies about the way nutrition is incorporated into nursing/midwifery courses across Australia have been identified (Schaller and James 2005). The Standards of Accreditation of Nursing and Midwifery Courses Leading to Registration in Australia (Australian Nursing and Midwifery Council 2009) have no content about nutrition. Furthermore, there is nothing specific about nutrition competencies mentioned in the standards of competencies document for Australian midwives by the Australian Nursing and Midwifery Council (ANMC) (Australian Nursing and Midwifery Council 2006). This is in stark contrast to United States of America programmes for midwives, which highlight the importance of having nutrition competencies, such as nutrition assessment, for their graduates (Touger-Decker et al. 2001).

From the above, it would appear that there has been no expectation that midwives undertake the role of providing nutrition education for pregnant women in Australia. However, this situation may be changing, as a recent report on core competencies and an educational framework for primary maternity services in Australia identified that the role of midwives includes the promotion of healthy eating (Homer et al. 2010).

2.3.5 Conclusion

This literature review has shed light on the limited information available on the current role of midwives in nutrition education during pregnancy. There has been little international and Australian research reported examining the role of midwives in nutrition education during pregnancy and the nutrition curricula of midwifery programmes.

Midwives were reported to share a belief in the importance of nutrition during pregnancy and the significant role they should play in educating women about nutrition. However, some midwives self-reported a lack of basic knowledge of nutrition requirements during pregnancy.

The lack of basic nutrition knowledge among some midwives may be linked to inadequate nutrition education provided in both undergraduate and postgraduate midwifery programmes and the apparent low priority put on nutrition education in midwifery education, as signified by its absence (Touger-Decker et al. 2001, Schaller and James 2005, Australian Nursing and Midwifery Council 2006, Australian Nursing and Midwifery Council 2009). Unlike other countries (National Institute for Health and Clinical Excellence 2008), Australia also lacks

29

scientific guidelines regarding nutrition in pregnancy that has been specifically tailored to the needs of midwives.

More research is required in this vital area as a first step towards better nutrition education for midwives and ultimately better nutrition information/education for future mothers and generations.

2.3.6 Acknowledgment

The authors would like to thank Elaine Newby who helped the editing of this review.

The next section will present the extended literature review.

30

2.4 Extended literature review

2.4.1 Preface

The initial literature review, published in 2014, concluded with some key points in relation to the nutrition education roles of midwives including: the paucity of research available in this area, midwives’ shared positive attitudes towards the importance of nutrition during pregnancy and the significance of their role in supporting pregnant women, and midwives’ suboptimal nutrition knowledge, probably due to lack of nutrition education before and after registration. There also seemed to be a lack of midwifery guidance (especially in Australia) about the position of nutrition in midwifery education or practice. This information informed the development and methods of the research.

Due to the editorial restrictions that limited the length and the number of references used in the published review, an additional section is presented below. Moreover, since the publication of the literature review, there has been a noticeable increase in published research related to all areas of nutrition during pregnancy, reflecting increased interest in this subject and awareness of its importance. An update of the literature presented in the previous published review is included. This update of the literature review focusses on: midwives and nutrition education during pregnancy including: their knowledge and confidence, sources of nutrition information obtained by midwives, midwives as providers of nutrition information during pregnancy and their perceptions regarding their professional role in this area; sources of nutrition information; what is being taught in midwifery programmes about nutrition during pregnancy, and nutrition education received by midwives. Consistency with findings from the previously published literature review will be discussed. The review has a primary focus on Australian research but will include international literature where relevant.

2.4.2 Midwives and nutrition education during pregnancy including: nutrition knowledge and confidence

The initial review identified that midwives overall lacked adequate general knowledge about nutrition during pregnancy (Arrish et al. 2014). Qualitative Australian and international studies continued to signal health care providers’ (including midwives) lack of knowledge in key areas, such as obesity and weight gain, and lack of confidence in discussing these issues with pregnant women (Olander et al. 2011, Willcox et al. 2012, Chang et al. 2013, Furness et al. 2014). More recent quantitative Australian studies reported health care providers’

31 (including midwives) low level of awareness of weight gain guidelines, skills necessary for weight management (Wilkinson and Stapleton 2012, Biro et al. 2013, Wilkinson et al. 2013), and the role and importance of iodine (Lucas et al. 2014b). The findings of these Australian studies are consistent with two international studies during this same period (Williamson et al. 2012, Macleod et al. 2013). Apart from obesity and weight gain, there continues to be no quantitative Australian study investigating midwives’ general nutrition knowledge and confidence in providing general and specific nutrition advice.

2.4.3 Midwives as providers of nutrition information during pregnancy and their perceptions regarding their professional role in this area

The initial literature review identified that midwives shared a belief in having a significant role to play in advising pregnant women about their diets and engaged in providing dietary advice (Arrish et al. 2014). Since that time, a few studies about midwives’ provision of nutrition advice in the United Kingdom (UK) and New Zealand have been published. The majority of the midwives in two studies reported discussing nutrition with pregnant women (Farrar 2013, Pan et al. 2014). The midwives in the UK study (n = 137) discussed a variety of nutrition topics with healthy eating, breastfeeding related advice and types of foods being the most frequently discussed, while other important topics, such as recommended weight gain and calorie intake, were the least frequently discussed (Farrar 2013). Limited time was proposed as the reason why all pertinent nutrition topics were not discussed, as half of the midwives spent less than 15 minutes discussing nutrition across the entire pregnancy (Farrar 2013). For New Zealand midwives, portion size was the least discussed topic (Pan et al. 2014). Lack of knowledge of those areas of nutrition also could be a reason for not discussing some nutrition topics. It is not known whether Australian midwives provide nutrition advice and, if so, what topics they usually discuss. Hence, research investigating this area was necessary.

The need for further research in this area has been supported by recent Swedish research that investigated midwives’ perceptions of their role in dietary counselling. The research found that midwives perceived themselves as an authority who lacked enough knowledge to counsel pregnant women especially on challenging issues, such as obesity, or when advising women from different cultural backgrounds (Wennberg et al. 2014, Wennberg et al. 2015). Similarly Australian qualitative research investigating midwives’ views and practices about weight gain and obesity found that midwives perceived themselves as the main providers of lifestyle

32 advice but that they lacked confidence and communication skills in approaching sensitive topics, such as weight management and obesity (Willcox et al. 2012). Cheyne and Moreno- Black (2010) argued that midwives’ nutrition counselling was related to their model of care. Midwives’ model of care has a focus on promoting health and wellbeing rather than managing diseases (Australian College of Midwives 2004). Similarly, the midwives in the study perceived food and nutrition as tools to promote the health and the wellbeing of the mother and the baby (Cheyne and Moreno-Black 2010). Recent increases in overweight and obesity rates (Australian Bureau of Statistics 2013) might act to change midwives’ perceptions and practices in this area. More exploration of this area was needed, especially on the possible effect of the model of care on the way midwives provide nutrition advice; the barriers that hinder their role; and the facilitators that may help them to provide better nutrition advice to pregnant women.

2.4.4 Sources of nutrition information

Contrary to the findings in the published literature review (Arrish et al. 2014) where the media was the main source of information UK midwives used as the basis of their nutrition advice, professional guidance and education were the most used sources reported in a recent UK study (Farrar 2013). The media, however, continued to be a main source of nutrition information. Half of the participant midwives used it compared to only 15% using the hospital dietitian (Farrar 2013). This is of concern as information from the media may lack credibility and should be treated with caution. The dietitian, as a nutrition expert, should be used more often as a source for up to date evidence-based information. There is still no available information on the sources Australian midwives use to gain their nutrition knowledge.

2.4.5 Nutrition education during midwifery education and during practice

Accreditation of professional programmes is based around knowledge and skills considered to be important for professional practice. In the published review, there was no mention of nutrition either in the Midwifery Accreditation Standards or in the National Competency Standards for the Midwife (Arrish et al. 2014). The Midwifery Accreditation Standards have been recently revised (Australian Nursing and Midwifery Accreditation Council 2014) with no significant changes in this regard. They still do not stipulate any specific nutrition education to be included in the curriculum. This is not in line with the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice

33

(International Confederation of Midwives 2010 pp. 8 and 9) (revised 2013), which indicates that it is a requirement for midwives to have ‘the knowledge and/or understanding of nutritional requirements of the pregnant woman and foetus’ and ‘the skill and/or ability to assess maternal nutrition and its relationship to foetal growth’ as well as be able to ‘give appropriate advice on nutritional requirements of pregnancy and how to achieve them’.

Midwives would need adequate education to provide such advice but research reporting on the nutrition education in midwifery curricula is still scarce. One recent study has been identified. A mixed-methods study in the UK investigating public health education, including maternal nutrition, reported that the education was mostly integrated in the curricula instead of being presented as a discrete unit. Hours allocated to ‘maternal nutrition’, ‘obesity’, and ‘weight management’ topics within public health curriculum were limited, with a total duration of less than 10 hours (McNeill et al. 2012).

From the perspectives of the midwives and consistent with the findings of the initial review, international and Australian studies have reported a lack of education about particular aspects of maternal nutrition, especially obesity and weight management (Wilkinson and Stapleton 2012, Willcox et al. 2012). Lack of education was identified by health care providers (including midwives) in a recent systematic literature review as one of the barriers for not providing nutrition advice to pregnant women in addition, to a lack of time and resources (Lucas et al., 2014). Health care providers, including midwives, continue to report the need for receiving continuing professional education about prenatal and postpartum nutrition (Hughes et al. 2011, Farrar 2013). There remains a paucity of research about nutrition education provided in Australian midwifery programmes or nutrition education received by Australian midwives during their practice.

2.4.6 Conclusion

This chapter comprising background information, a published literature review and a subsequent update illustrated the importance of nutrition during pregnancy for the health of the mother and the baby but pointed out that pregnant women dietary behaviours and knowledge do not align with this importance. Despite the availability of growing evidence indicating that dietary advice can reduce gestational weight gain and may reduce the incidence of some poor pregnancy outcomes, the provision of antenatal nutrition advice during pregnancy is not a common practice. The midwife, who is ideally placed to provide such advice, has been the focus of little research in this area according to the published

34

literature review presented here. Midwives were found to have positive attitudes towards nutrition during pregnancy and their role as educators in nutrition but reported a lack of knowledge of nutrition requirements and inadequate confidence due to that lack of education. While an update of the published literature has reflected increased research about health care providers (including midwives) in the areas of knowledge and practice relating to weight gain and obesity, the findings of this update are consistent with the findings of the published review (Arrish et al. 2014) where lack of knowledge and education continues to be evident. There continues to be limited quantitative research about Australian midwives’ nutrition knowledge, attitudes, confidence in providing nutrition advice and more in-depth understanding of their perceptions of this role. Additionally, despite the update of the Australian Midwifery Accreditation Standards, nutrition remains neglected with no specific guidance for the profession. There is also still a paucity of research about nutrition education received by midwives during practice or in midwifery education. The next chapter will discuss in detail the methodology of this thesis and the research methods employed to address those gaps.

35

3 METHODOLOGY

3.1 Preface This chapter outlines the overall research methodology. As highlighted in the previous chapter of the literature review (Chapter 2), good nutrition during pregnancy is fundamental for maternal and foetal health, and midwives potentially have a vital role to play in providing effective nutrition advice to pregnant women. The aim is to support pregnant women make informed decisions about their diets so as to improve health for themselves and their babies. The literature review confirmed that research about the role of midwives in providing nutrition advice, their knowledge, or the preparation they receive to undertake this role is scarce. Therefore, this thesis aimed to address this gap.

Specific objectives to achieve this aim were determined. These objectives included:

1. To determine the level of nutrition knowledge and attitudes of Australian midwives and their confidence in providing nutrition education during pregnancy.

2. To investigate the nutrition education received by practising midwives.

3. To explore midwives’ understanding and perceptions of their roles in nutrition education.

4. To review the nutrition content of curricula in midwifery programmes around Australia.

5. To provide recommendations from phase 1, 2, 3 and 4 to improve the provision of nutrition education in Australian midwifery programmes and to assist midwives to integrate nutrition education into their practice.

In order to achieve these objectives, quantitative and qualitative studies were undertaken using a mixed-methods approach. The overall thesis has two arms: the practitioners’ arm (i.e. midwives) and the education providers’ arm (i.e. coordinators). Each arm has used both quantitative and qualitative approaches. The chapter begins with an explanation of the overall approach chosen for this thesis, the philosophical assumptions underpinning this approach, the research design, the conceptual framework and the research methods (i.e. quantitative and qualitative) for the two arms of the study, including: data collection, data analysis, and any other related aspects. As this dissertation is presented as a thesis by compilation, each subsequent chapter or manuscript includes a description and discussion of the relevant

36 methods. This chapter presents the overall methodology and methods of this thesis, including some aspects that have not been elaborated on in the published articles here appearing as chapters due to limitations imposed by journal publication requirements.

3.2 Research approach Mixed-methods is the approach used for this thesis. The use of mixed-methods research as a distinctive approach from quantitative and qualitative approaches in the social and behavioural sciences has evolved during the last two decades (Creswell and Clark 2011). There has been an increased use of mixed-methods approaches in health related research due to their perceived value in enriching the data and improving the quality of the evidence (Creswell et al. 2011). As the area of midwives and nutrition was relatively not researched, this thesis utilised a mixed-methods approach including both quantitative and qualitative methods to investigate various aspects (i.e. knowledge, role, and education) and provide a broad and deep understanding of these aspects. This rational is further supported by the following definition of a mixed-methods approach by Creswell and Clark (2007 p. 5) as

a research design with philosophical assumptions as well as methods of inquiry. As a methodology, it involves philosophical assumptions that guide the direction of the collection and analysis of data and the mixture of qualitative and quantitative approaches in many places of the research process. As a method, it focuses on collecting, analysing, and mixing both quantitative and qualitative data in a single study or series of studies. Its central premise is that the use of quantitative and qualitative approaches, in combination, provides a better understanding of research problems than either approach alone.

Specific reasons for using mixed-methods approach combining both quantitative and qualitative methods in this thesis were: complementarity (using the results of one method to elaborate, enhance, or clarify the results obtained from another method) and expansion (expanding the depth and breadth of the study using different methods for various components of the research) (Creswell and Clark 2011).

3.3 Philosophical assumptions The philosophical assumption underpinning the mixed-methods approach used in this study is pragmatism (Creswell 2009). Central foci to a pragmatic perspective are the applications (what works) and the solutions to problems. The problem is more important than the method, and in order to understand the problem, the researchers use all approaches (Creswell 2009). Within this philosophy, the pragmatic researchers do not commit to one philosophy; they are

37

free to draw upon both quantitative and qualitative assumptions while conducting their research (Creswell 2009).

Since the aim of this thesis was to explore the area of nutrition and midwives (including their nutrition knowledge, the perceptions of their role, the education they receive and the nutrition content provided by the educational institutions of the profession), the perspectives of the practitioners (i.e. the midwives) and the education providers (i.e. the course coordinators) were deemed necessary to provide richer data. Additionally, based on the literature review, some aspects required quantitative methods by their nature (i.e. knowledge, attitudes, confidence and nutrition content in midwifery programmes) (Barrowclough and Ford 2001, Touger-Decker et al. 2001, Elias and Green 2007), while others required qualitative methods (i.e. hearing from the individuals themselves, the perceptions of midwives of their role in providing nutrition advice and perspectives of midwifery course coordinators of how nutrition is incorporated into their curricula) (Cheyne and Moreno-Black 2010, Bondarianzadeh et al. 2011). The mixed-methods approach has also been used in earlier international exploratory research about the midwife’s nutrition knowledge, attitudes, and education (Mulliner et al. 1995). Therefore a mixed-methods approach with a pragmatic perspective was considered the most relevant for this thesis.

3.4 Research design The thesis has two arms: the practitioners’ arm (i.e. midwives) and the education providers’ arm (i.e. midwifery course coordinators). Quantitative and qualitative data were collected from both arms. According to Creswell and Clark (2011), mixed methods as an approach has four basic designs: convergent parallel, explanatory sequential, exploratory sequential, and embedded design. The overall thesis (practitioners’ arm and the education providers’ arm) followed the principles of convergent parallel design, which is the most frequently used design (Figure 3.1) p. 39. In this design, the collection and analysis of quantitative and qualitative data occurs separately but in the same period of the research process (ideally given the same priority) and the merging of the findings from both data sets occurs in the overall interpretation (Creswell and Clark 2011). Obtaining a comprehensive understanding of the topic under study and validating or corroborating the findings from one method with the findings of the other is the core purpose of this design (Creswell and Clark 2011).

38

Figure 3.1: A diagram of the mixed-methods design of the overall thesis

39 The main focus of the overall thesis was exploring the issue of midwives’ roles in nutrition education from the perspectives of practising midwives and as reflected in midwifery education. Research explored practising midwives’ levels of nutrition knowledge as well as their attitudes and confidence in providing nutrition advice, the nutrition education they had received to prepare them for this role, and their perceptions of this role. Exploring midwifery education provided insights into the breadth and volume of nutrition content of midwifery programmes in Australia to reflect on the preparation of graduate midwives for this role, as well as the views of midwifery coordinators regarding nutrition education within their programmes and midwives’ role in this area. For the purpose of this study, the core component was gaining insights from the midwives themselves. The coordinators’ arm was included to expand the depth and breadth of the study by including different perspectives (Creswell and Clark 2011).

Consistent with the convergent parallel design, data collection and analysis for the quantitative and qualitative studies were undertaken separately within each arm of the thesis. The reasons for using a mixed-methods approach in these studies were similar to the reasons for using it for the overall thesis and these were: complementarity (using the results of one method to elaborate, enhance, or clarify the results from another method) and expansion (expanding the depth and breadth of the study using different methods for various components of the research) (Creswell and Clark 2011).

Data merging or point of interface for the data occurred at two points (Figure 3.1) p. 39. For the education providers’ arm, data merging firstly occurred within the arm; this is presented in the discussion of Chapter 7. For the practitioners’ arm, data merging was not undertaken within the arm but occurred later, in the analysis of the overall results. This is presented in Chapter 8. However, as the thesis style is by compilation, a cross reference among the included studies has been made in the published articles.

Some of the advantages of using the convergent parallel design include: the possibility of providing more reliable findings; time efficiency in collecting the data where quantitative and qualitative data could be collected within the same time frame; provision of more complete knowledge to inform theory and practice; and addition of insights that might be missed if using only one method (Johnson and Onwuegbuzie 2004). However, the design is not without limitations. Collecting two sets of data within the same time frame can be a challenge for a single researcher (Johnson and Onwuegbuzie 2004). In this thesis this limi-

40 tation was overcome by using efficient tools to collect the data. Quantitative data were collected using online surveys while the qualitative data were collected using telephone interviews. Both tools are flexible and easy to manage by a single researcher. Another potential limitation is that using different types of methods requires the researcher to gain extensive knowledge of these methods and how to apply them (Johnson and Onwuegbuzie 2004). This was addressed by a number of strategies including: having supervisory support that included expertise in both quantitative and qualitative methods; attending a number of workshops and training sessions about different aspects of the two methods; and general reading of books and peer-reviewed articles related to mixed-methods research.

3.5 Conceptual framework A conceptual framework can be defined as a visual or written illustration of the main variables, factors or concepts the researcher intends to study, including the hypothesised relationships among those variables, factors, or concepts (Maxwell 2013). Figure 3.2 p. 43 illustrates the conceptual framework of this thesis and the hypothesised inter-relationships among the key variables that will be explored in this thesis either quantitatively or qualitatively. The framework was based on a review of the literature.

The central focus of this thesis is the variables/factors affecting midwives’ behaviour of providing nutrition advice. Any interaction between midwives and pregnant women in this area will be influenced by midwives’ knowledge, attitudes and skills. The relationship between knowledge, attitudes, and behaviour has been proposed theoretically by the Knowledge-Attitude-Behaviour model (KAB) (Bettinghaus 1986). The KAB model occasionally known as the knowledge-attitudes-skills behaviour model is possibly the oldest model among known behaviour models. It is the model that has been underpinning the majority of educational interventions (Bettinghaus 1986). Knowledge build-up is the key resource in this model (Baranowski et al. 2003). The KAB model proposes that as knowledge increases, attitudes change; and that these changes in attitude promote behaviour change (Baranowski et al. 2003). Although this model has been criticised for its suggestion of the simplicity of the relationship between those variables, the correlations between knowledge and behaviour or between attitude and behaviour are generally positive, though low (Bettinghaus 1986). If the KAB model is to be applied to the provision of nutrition advice, it would require the midwife to gain knowledge of the basic principles and benefits of healthy eating during pregnancy to develop positive attitudes about the importance of nutrition during 41 pregnancy and the significance of their role in supporting women about it, and to acquire the necessary skills to overcome any barriers that may hinder the provision of nutrition advice. However, this model assumes that knowledge alone affects the behaviour, which is inaccurate. It only takes into account personal factors and ignores environmental factors that also influence the behaviour (Baranowski et al. 2003). Therefore, knowledge can be a part of a larger conceptual framework that offer some explanation of behaviour change, but increasing knowledge alone is not sufficient in promoting behaviour change (Baranowski et al. 2003).

One of the other factors that are assumed to influence midwives’ behaviour of provision of nutrition advice and the KAB does not account for is confidence or self-efficacy. According to Bandura (1977), a relationship exists between confidence or self-efficacy and behaviour change. This concept of specific self-confidence related to a particular act or task (i.e. the belief in one’s ability to perform a particular behaviour) was first introduced by Bandura (1977). It is assumed that the more confident midwives feel in providing nutrition advice the more likely they will provide such advice. Confidence is also assumed to be related to knowledge. Increase in knowledge may increase confidence (Chang et al. 2008). Education also affects knowledge (Barrowclough and Ford 2001) and behaviour (Hillenbrand and Larsen 2002, Baghianimoghadam et al. 2012). Other identified factors that may influence midwives’ provision of nutrition behaviour include: model of care, role perceptions (Cheyne and Moreno-Black 2010) , and barriers and facilitators.

Although the midwives’ behaviour of providing nutrition advice was the centre of the conceptual framework of this thesis (Figure 3.2 p. 43), the direct relationship between the behaviour and the included factors was not investigated quantitatively. The focus was on exploring the factors that were assumed to influence this behaviour. The main emphasis in the upper half of Figure 3.2 p. 43 was knowledge. The research investigated the relationship between: knowledge and education, knowledge and attitude, and knowledge and confidence quantitatively using surveys. It also investigated if these factors could explain the variance in knowledge. There were also open-ended question components generating quantitative and qualitative data from the survey that might provide further understanding about those factors. The thesis explored the factors on the lower half of Figure 3.2 p. 43 (namely, model of care, role perceptions and barriers/facilitators) qualitatively. It explored how these factors affect the way midwives provide nutrition advice to pregnant women using interviews.

42 Education Knowledge Confidence

Attitudes

Behaviour (Provision of nutrition advice)

Model of care Role perceptions Barriers/facilitators

Figure 3.2 : The conceptual framework underpinning this research

3.6 Research methods

Data collection and analysis for the two arms of the thesis (i.e. professionals and education providers) in this mixed methods approach are presented in the next section.

3.7 The practitioners’ arm Two studies were undertaken within this arm. The first was a quantitative study and was undertaken to provide a ‘snapshot’ of Australian midwives’ general nutrition knowledge, received nutrition education, their attitudes, and their confidence in providing nutrition advice during pregnancy. The second study was a qualitative study and was undertaken to gain an in-depth understanding of midwives’ perceptions of the importance of nutrition, how they perceived their role in educating women about nutrition, and what facilitated or hindered this role.

43 3.7.1 The quantitative study

3.7.1.1 Study design The study used a descriptive, cross-sectional design utilising an online survey.

3.7.1.2 Sampling and recruitment The sampling strategy used in the quantitative study of the midwives was convenience sampling. Convenience sampling is one of the types of non-probability sampling strategies. These strategies are usually based on the judgment of the researcher and do not employ probability techniques. In convenience sampling the researcher selects the sample based on the ease of access to the target population. Additionally, convenience sampling is time and cost efficient in comparison to probability sampling. However, as the sample is not chosen randomly, the generalisability of the data from a convenience sample is limited because of selection bias. Additionally, the characteristics of the sample might not be typical of the general population. A high level of non-response may occur because of the voluntary nature of this sampling strategy and is also considered a limitation of this type of sampling (Etikan et al. 2016).

In this study, the professional association for the Australian midwives, namely the Australian College of Midwives (ACM), was chosen as an inexpensive and time efficient avenue to access large numbers of midwives from across Australia, thus maximising the sample size. Probability sampling was not possible as the researcher had no access to the emails of the members because of confidentiality issues. Recruitment therefore occurred through ACM officers. An invitation with a link to the survey was placed in the ACM newsletter (see Appendix I) and an invitation email via the ACM office was also sent to its 4770 members in August 2012, followed by two email reminders sent at monthly intervals (Appendix K).

Although the sample was a convenience sample, the minimum sample size required was estimated through statistical calculation to ensure sufficient statistical power. The estimated minimum sample size required was 356. The calculation was based on a total population of 4770, margin error of 5, and a confidence level of 95% (Raosoft 2004).

3.7.1.3 Survey development There was paucity of literature about the nutrition knowledge of midwives. At the time of commencing this study, there were three identified studies that had examined midwives’

44 nutrition knowledge, attitudes, and confidence in providing nutrition advice (Mulliner et al. 1995, Barrowclough and Ford 2001, Elias and Green 2007). The actual surveys used in these studies were not available, and the most recent one could not be obtained even after contacting one of the authors. Therefore, the development was informed by these studies rather than through the use of the same questions. Questions about generally important issues related to nutrition in pregnancy were also included in the survey.

3.7.1.4 Survey structure The survey included four sections: nutrition education; attitudes towards and confidence in midwives’ provision of nutrition education during pregnancy; pregnancy general nutrition knowledge; and demographic characteristics. As the nature of this thesis was primarily exploratory, there was an intention to develop a general short survey, especially in the area of nutrition (knowledge was one element of this thesis not the main focus); therefore, one or two questions about each area related to nutrition during pregnancy were included. The survey instrument is provided in Appendix L.

3.7.1.4.1 Section 1: Nutrition education Two questions elicited information about any education about nutrition participants had received either in their initial midwifery programme or following registration. If they responded with a ‘yes’ to either of these questions, they were then asked to respond to two open-ended questions that explored further the volume of education and where it was provided.

Additionally, for the participants who answered ‘yes’ to one or both of the questions they were directed to another page to provide the details of this education (including information on who provided it and the nutrition topics covered).

3.7.1.4.2 Section 2: Attitudes and confidence towards the provision of nutrition education during pregnancy As was illustrated in the conceptual framework of this thesis (Figure 3.2) p. 43, attitudes and confidence have been linked to behaviour. Therefore, questions about midwives’ attitudes towards the importance of nutrition during pregnancy for the health of the mother and the baby and the significance of their role in providing women with nutrition advice and support during this vital period have been included in this section. Midwives’ actual behaviour of providing nutrition advice and confidence in providing such advice were also assessed.

45 The section included two questions that required the respondents to rate them, using five- point scales. These involved: the views of midwives of the importance of nutrition during pregnancy (‘very important’, ‘moderately important’, ‘important’, ‘slightly important’ and ‘not important at all’) and the significance of their role in providing nutrition education to pregnant women (‘very significant’, ‘moderately significant’, ‘significant’, ‘slightly significant’, ‘not at all significant’). The respondents were also asked whether they provide nutrition advice to pregnant women and, if so, to rate their level of confidence in discussing general or specific nutrition issues with pregnant women (‘very confident’, ‘moderately confident’, ‘confident’, ‘slightly confident’ ‘not at all confident’); when they discuss these issues; and what sources they usually use as the basis of this advice. There were two other additional questions that asked the respondents if they have access to dietetic services at their workplace and, if so, whether they make referrals and for what reasons. There were also two questions asking respondents about their views on receiving more nutrition information or education; and on having specific guidelines tailored for them to provide nutrition advice. The midwives were asked to provide reasons for any answer they choose for these two questions.

3.7.1.4.3 Section 3: Pregnancy general nutrition knowledge This section assessed midwives’ general nutrition knowledge about nutrition during pregnancy. This section included 12 items consisting mainly of two types: single-answer items (n = 8) and multiple-answer items (n = 4). Type of knowledge required to answer the questions included declarative knowledge and procedural knowledge. The questions covered knowledge areas that have direct implications for the health of the mother and the foetus and require attention from health professionals in terms of education and support or were reported in the previous literature (Mulliner et al. 1995, Barrowclough and Ford 2001, Elias and Green 2007). Hence, it was deemed necessary to investigate midwives’ knowledge of those areas.

The single-answer items included questions about the respondents’ knowledge of: average change in energy requirements during pregnancy; whether there is a difference in the energy requirements for pregnant women during the three trimesters of pregnancy; the range of healthy weight gain during pregnancy for a woman who commenced her pregnancy at normal weight; the most important vitamin supplement for vegetarian pregnant women; when women should take folic acid supplement and the amount of folic acid supplement needed daily during pregnancy; the recommended number of serves of dairy foods required

46 per day to meet pregnant women’s requirements for calcium; and iodine requirements per day for a pregnant woman.

The four multiple-answer items included questions about: foods that should be avoided in pregnancy as a risk of listeria; food sources of iron; advice to minimise the effect of nausea and vomiting during pregnancy; and foods to assist with resolving constipation during pregnancy. The respondents were instructed to choose the correct answer from the given options. The ‘I do not know’ option was added to prevent guessing when the respondents were not sure of their answers and was coded as ‘incorrect’ answer in the statistical analysis (Sarmugam et al. 2014).

Each single-item question had one correct answer and was given a score of one for each correct answer, giving them a total score of eight. Multiple-answer items had more than one correct answer and a score of one was given to each correct answer in each question, giving them a score of 12. The answers to the multiple-answer items were independent of each other. If the question had three correct answers, the respondent obtained a score of three out of three if all correct answers were chosen, and two out of three if two correct answers were chosen and so on. An overall maximum score of 20 was given to the knowledge section by combining the score of the single and multiple answer items.

3.7.1.4.4 Section 4: Demographic characteristics This section of the survey collected demographic data of the respondents and included their gender, age category, midwifery education, years of experience, and principal state or territory of work. The survey was designed for and promoted as being for practising midwives who are actively involved in providing antenatal care either in hospitals or independently; therefore, respondents were asked to indicate their place of practice, level of maternity services, and areas of maternity practice. The purpose of including the mentioned demographics was to describe the profile of the Australian midwives participating in the study and to investigate whether there is any association between these demographics and midwives’ nutrition knowledge. Previous international studies did not find any association between midwives’ nutrition knowledge and their age, midwifery education, years of experience, and nutrition education (Mulliner et al. 1995, Elias and Green 2007).

47 3.7.1.5 Survey validity Content-related validity was undertaken for the survey. Five academics with different expertise (nutrition and dietetics, public health nutrition, midwifery, and statistics) participated in the review process and provided feedback on the survey. Pilot testing of the survey was undertaken first with five nutrition researchers at the University of Wollongong and then with a sample of five practising midwives. Amendments were made according to the feedback received from the experts and the respondents. These amendments included: adding a few questions, modifying existing ones, and reducing ambiguity.

3.7.1.6 Data processing The raw data from the survey were downloaded from Survey Monkey Software into the Statistical Package for the Social Sciences Software (SPSS) version 22 (Armonk, NY: IBM Corp.) for analysis. Firstly, the data were cleaned. The responses were checked for missing data. Incomplete surveys were excluded from the analysis to deal with the issue of missing data. Any outliers were also identified and checked. The data were then coded. The open- ended components were also checked for accuracy and usability. The answers were read and reread several times to get familiar with the data and start the organisation process.

3.7.1.7 Data analysis

3.7.1.7.1 Statistical analysis Two types of statistics were used, descriptive and inferential statistics. Descriptive statistics included: means and standard deviations, frequencies, and percentages. Inferential statistics included: bivariate statistics and multiple linear regression. Bivariate statistics, such as the independent t test (for variables with two categories) and one way ANOVA (for variables with more than two categories), were used to explore the effect of demographic characteristics on midwives’ knowledge. Multiple linear regression analysis was used to explain the variance in nutrition knowledge. Significance for all tests was set at alpha level of 0.05.

3.7.1.7.2 Analysis of open-ended questions The survey included open-ended questions and some spaces to enable respondents to elaborate on their answers or provide further information. Due to participants providing large volumes of text, qualitative content analysis was chosen to analyse these questions descriptively (Elo and Kyngas 2008).

48 Content analysis is a method used to analyse textual, verbal or visual qualitative data (Elo and Kyngas 2008). It is a systematic way to quantify and describe phenomena in a condensed and broad manner in the form of concepts or categories (Elo and Kyngas 2008). The approach used to analyse the data was inductive. This approach was most relevant as there was little knowledge about nutrition advice provided by the midwives and the categories were derived from the data (Elo and Kyngas 2008).

The analysis was conducted through a series of steps. It started with organising the data through open coding, creating categories and abstractions (Elo and Kyngas 2008). The text of different questions was read and reread to become immersed in the data. Open coding and formation of categories was then undertaken. Similar categories were grouped in a hierarchical format, moving from specific to general, to either form general descriptions of the data or increase understanding of the data through a process of abstraction (Elo and Kyngas 2008). The validity of the analysis was established through reviewing and discussing the final categories with the supervisory research team until agreement was reached (Graneheim and Lundman 2004).

3.7.2 The qualitative study

3.7.2.1 Design A descriptive qualitative approach (Neergaard et al. 2009) was also undertaken to generate rich and truthful data for a deeper understanding of midwives’ roles in nutrition education (O’Leary 2004) and address the research aim to describe participants’ experiences and perceptions about their roles (Neergaard et al. 2009). Semi-structured interviews were chosen because they are flexible in style, incorporating open-ended questions that allowed respondents to give their answers in their own words and to express their ideas and opinions (O’Leary 2004).

3.7.2.2 Sampling and recruitment The sample was a convenience sub-sample drawn from the sample of the ACM members who completed the online survey. An introduction about follow-up interviews to further explore midwives’ roles in providing nutrition advice was presented in the participation information sheet provided as a first page of the online survey (see Appendix L). At the end of the survey, participants who were interested in being involved in the interviews were directed to another page to provide their consent to be contacted. The new page requested

49 them to provide their contact details (i.e. name and email address) (see Appendix M). There was an intention to interview midwives from different ages and with various work experience, and thus information about age category and years of experience was also requested from the participants. Midwives who consented to be contacted were formally invited in October 2012 via email (including the participation information sheet and the consent form). Two reminders were sent to non-respondents. Participants who returned their signed consent forms were sent a form to: indicate their preferred option for the interview (Skype or telephone); provide their phone number if they chose the telephone or their Skype account’s details if they chose Skype; and provide their preferred dates for the interviews.

3.7.2.3 The interview guide An interview guide was developed by the researcher and reviewed by the supervisory team, two experts (midwifery and public health), and a dietitian. Midwives were asked about: their model of care and how it affects provision of nutrition advice; their views of the impact of maternal nutrition on the mother and the baby; nutrition issues they discuss with pregnant women; and their perceptions of their role in this area (including the preparation they receive to undertake this role, the barriers, facilitators, and available resources) (see Appendix N).

3.7.2.4 Data analysis The interviews were analysed using thematic analysis. Thematic analysis is a process of generating and exploring relevant themes in order to move from raw data to meaningful understanding. This can either be undertaken through inductive analysis or through engagement with the literature prior to data collection. The themes can also emerge through the process of data collection by reading, overviewing, and annotating the text prior to systemic thematic coding (O’Leary 2004). Thematic analysis can involve the use of a number of tools or devices. These include: exploring words, exploring concepts, exploring linguistic devices, and exploring non-verbal cues, in addition to exploring interconnections among themes (O’Leary 2004).

The interviews were transcribed by a professional transcriber and checked for accuracy and analysed by the student researcher. The QSR International’s NVivo11 was used to assist managing the coding of the data. The student researcher read and reread the transcripts to become familiar with the data. The student researcher referred to the recordings regularly to allow for contextual interpretation of the data. An inductive open coding of the transcripts was undertaken. The student researcher and one of the supervisory team

50 undertook independent coding to ensure agreement of coding and establish validity. The student researcher then organised the descriptive themes and completed the analysis, then verified the findings with the supervisory team.

3.8 The education providers’ arm

3.8.1 The quantitative study

3.8.1.1 Study design The design employed by this descriptive study was a cross-sectional online survey.

3.8.1.2 Sampling and recruitment Non-probability, purposive, specifically total population sampling was undertaken by the researcher. The sample comprised an entire population, Australian midwifery educators, as the population was small and has specific characteristics relevant to the research question (Etikan et al. 2016).

The advantage of total population sampling is that it includes all the members of the population of interest, so there is an opportunity for obtaining a wide coverage of the population and less chance of missing members of the population. However, as the strategy belongs to the non-probability strategies, generalisability is limited, especially if not all the members of the population choose to participate in the study. The researcher planned to sample the whole population and compiled a whole list of the population, as it was non- existent at the commencement of the research. The process of total population sampling included: defining the specific characteristics of the population, creating the list of the population and contacting all the members on the created list (Etikan et al. 2016).

A list of all 50 accredited midwifery programmes in May 2012 was obtained from the website of the National Nursing and Midwifery Board of Australia (NMB). These 50 programmes included 23 undergraduate and 27 postgraduate degrees from 29 universities. The identification and contact details of course coordinators for the identified programmes were compiled by searching institutional websites and telephone enquiry.

The course coordinators of those programmes were chosen as the target population because they were deemed the individuals who were most knowledgeable about the nutrition content of their programmes as it was their responsibility to plan and coordinate the curriculums. The invitations to participate in the survey (with a link to the survey) were sent by email in June

51 2012 (see Appendix O). Three reminders were sent to non-respondents at one month, three months, and four months from the issue of the invitation.

3.8.1.3 Survey development Similar to the midwives’ survey, there was paucity of literature around nutrition education provided in midwifery programmes. Only one survey was located in the literature at the time of the study (Touger-Decker et al. 2001). The survey was based on United States of America’s (USA) specific nutrition competencies for midwives and therefore was considered not relevant to Australia for the purpose of this study. The researcher developed a short 10 item survey. The items included: how nutrition is included in the curricula of Australian midwifery programmes; who is providing this education; course coordinators’ views on midwives’ role in nutrition education; and their perceptions regarding the importance of nutrition in midwifery curricula. The survey instrument is included in Appendix P. The survey was reviewed by two experts (in public health nutrition and midwifery) and a dietitian. The survey was pilot tested with five researchers at the University of Wollongong and two course coordinators, one of whom was a coordinator of a midwifery programme.

3.8.1.4 Data analysis The data were downloaded from SurveyMonkey Software into the Statistical Package for the Social Sciences Software (SPSS) version 22 (Armonk, NY: IBM 154 Corp.) for analysis. Descriptive data including frequencies and percentages were presented. The Fisher exact test was used (due to small numbers) to examine the association between nutrition topics covered and programme type (i.e. undergraduate or postgraduate) and whether nutrition experts’ advice was sought in reviewing nutrition content. The association between hours allocated to nutrition and programme type was also explored. Statistical significance was set at alpha level of 0.05. The free text data were categorised and described.

3.8.2 The qualitative study

3.8.2.1 Design Similarly to the qualitative study of the practitioners’ arm, a qualitative descriptive approa- ch was chosen for the study (Neergaard et al. 2009) using semi-structured interviews.

52 3.8.2.2 Sampling and recruitment The coordinators were recruited through convenience sampling from the sample that completed the survey, as has been described for the practitioners’ arm. The participants were notified about the interviews and its purpose in an email invitation to participate in the survey (see Appendix O). Coordinators were asked to email if interested to participate, and those who established contact and sent their consent forms were contacted and interviewed. Further invitations for the interviews were emailed in January and February 2013. The student researcher conducted and recorded the telephone interviews between November 2012 and March 2013. They lasted between 11 and 26 minutes with an average time of 15 minutes.

3.8.2.3 The Interview guide The interview guide was developed by the student researcher and reviewed by the supervisory team, two experts (midwifery and public health), and a dietitian, and piloted with one midwifery course coordinator. The questions were about: the way nutrition is presented within the curriculum; the development and review activities of the nutrition curriculum; the theoretical or professional models underlining it; aspects that prepare the students to provide nutrition advice; and their readiness for such a role (see Appendix Q).

3.8.2.4 Data analysis Similarly to the analysis of the midwives’ interviews, thematic analysis was used to analyse the data in a descriptive style with the assistance of QSR International’s NVivo11 Software. The student researcher read and reread the transcripts to become immersed in the data. All the members of the research team coded one transcript independently and another transcript as a group, and discussed the coding. The student researcher then coded the remaining transcripts and discussed the coding of all transcripts with one or both of the supervisors until consensus was reached. The student researcher organised the descriptive themes, finalised the analysis, and confirmed the final results with the supervisory team.

3.9 Ethical considerations This research raised some ethical considerations concerning participants including: informed consent, confidentiality, anonymity, and ethical approval.

3.9.1 Informed consent

The participants in this research (including midwives and midwifery coordinators) are health professionals and university academics who were able to give their informed consent. The 53 content of the midwives’ and coordinators’ surveys and interviews focused on professional practice and education and were not of a personal nature. Thus it was not anticipated that there would be any discomfort or disadvantage that ensues from participation in the studies. In the surveys participants implied their consent by accessing and completing the online surveys (see consent statements on page 2 of Appendices L and Q). In the interviews, all participants consented to participate either orally or in a written format (see appendices S and U for consent forms). Participants were assured that they were free to refuse to participate or withdraw from the studies at any time and their refusal would not affect their employment or their relationships with the University of Wollongong.

3.9.2 Confidentiality

The protection of confidentiality is a priority and must be assured (O’Leary 2004). The participants were health professionals and university academics and assurance that participating, or not participating or withdrawing would not affect their employment was essential. Therefore, the identity of the participants (the midwives and the coordinators and their institutions) was concealed from all except the researcher who had access to the raw data provided by the participants. Ethical approval was obtained for having assistance in transcribing the interview data. During the research, electronic data were stored on a personal computer locked with a password, and hard copy format data were stored in a locked cupboard in the student researcher’s office at the University of Wollongong and only the student researcher and supervisors had access to them. After completing this research, all data will be kept for five years in a locked filing cabinet in a locked cupboard in the principal supervisor’s office at the University of Wollongong.

3.9.3 Anonymity

The surveys and the interviews were anonymous. The identity of the participants was not reported in any part of the research. The participants were notified of this information in the Participation Information Sheets (see appendices R and T). In the midwives’ knowledge survey, the participants were completely anonymous. No link could be established between the participants’ surveys and their identities. The midwives’ surveys for collecting their contact details for the interview could not be linked to their knowledge surveys. In the case of the midwifery coordinators, the identity of the coordinators that could be identified from their email addresses was hidden from anyone except from the student researcher and the

54 supervisors. With regard to the interviews, participants were de-identified using codes such as 'Midwife 1' and 'Coordinator Five'.

3.9.4 Ethical approval

Ethical approval was granted from the University of Wollongong Health and Medical Human Research Ethics Committee for all studies included within both arms (HE12/009 and HE12/038) (see appendices V and W). Minor amendments to initial ethical protocols were obtained as required (see appendices V and W).

3.10 Summary This chapter discussed the methodology this thesis intended to utilise including: an explanation of the overall approach chosen for this thesis, the philosophical assumptions underpinning this approach, the research design, the conceptual framework, and the research methods (i.e. quantitative and qualitative) for the two arms of the study, including data collection, data analysis, and any other related aspects. The next chapter will present the content of the first part of the quantitative study of the practitioners’ arm (i.e. the midwives).

55 4 AUSTRALIAN MIDWIVES AND PROVISION OF NUTRITION EDUCATION DURING PREGNANCY: A CROSS SECTIONAL SURVEY OF NUTRITION KNOWLEDGE, ATTITUDES, AND CONFIDENCE

4.1 Preface The chapter of the literature review (Chapter 2) identified the limited research investigating the behaviour of midwives in the provision of nutrition advice during pregnancy especially in terms of the elements that influence such behaviour (as explained in Chapter 3: Methodology) namely: their level of nutrition knowledge, nutrition education, attitudes towards the importance of nutrition, and the significance of their role in supporting women’s nutrition related health and their confidence when doing so. These elements represent the factors that this research intends to investigate in a quantitative manner as it was illustrated in the conceptual framework (chapter 3). International research indicated that despite having positive attitudes about maternal nutrition and their role in supporting it, midwives did not demonstrate adequacy in terms of knowledge, education, and confidence. It was important to investigate where Australian midwives stand in comparison to midwives in other developed countries in those areas which comprised the first research question.

This chapter reports on the findings from the quantitative study from the practitioners’ arm (i.e. midwives), as explained in the previous (methodology) chapter, whereby the members of the Australian College of Midwives (ACM) were surveyed. Information about midwives’ level of nutrition knowledge, nutrition education, attitudes, and their confidence in discussing nutrition with women was ascertained. This was deemed necessary to guide future educational interventions. The following chapter (Chapter 5) sheds more light on the details of the nutrition education that the midwives surveyed had received before and after being registered.

This chapter has been written and published during the course of this degree in the peer- reviewed journal of Women and Birth (see Appendix B).

Note: The article is presented as it was published with minor modifications in terms of formatting (such as figure and table numbering, and the referencing style) to ensure cohesion within the thesis and to conform to the University of Wollongong’s referencing style which is the Author-Date. The Author-Date style is used throughout the thesis.

Citation: Arrish, J., Yeatman, H. and Williamson M. (2016). "Australian midwives and provision of nutrition education during pregnancy: A cross sectional survey of nutrition knowledge, attitudes, and confidence." Women and Birth. 29(5): pp. 455–464. 56 Key findings have also been presented as a part of a symposium at the 30th conference of the International Confederation of Midwives in Prague 2014 (see Appendix G).

Arrish, J., Yeatman, H. and Williamson M. (2014). "Nutrition and pregnancy – What role for the midwife?." 30th Conference of the International Confederation of Midwives. Prague, Czech Republic, 1–5 June 2014. Authors’ contribution: J. Arrish was mainly responsible for survey design, data acquisition, data analysis and interpretation, and writing and submitting the manuscript. H. Yeatman and M. Williamson contributed to the conception of the study, design of the survey, and the development of the manuscript.

57 4.2 Abstract Background: Maternal nutrition during pregnancy affects the health of the mother and the baby. Midwives are ideally placed to provide nutrition education to pregnant women. There is limited published research evidence of Australian midwives’ nutrition knowledge, attitudes, and confidence.

Aim: To investigate Australian midwives’ nutrition knowledge, attitudes, and confidence in providing nutrition education during pregnancy.

Methods: Members of the Australian College of Midwives (n = 4770) were sent an invitation email to participate in a web-based survey, followed by two reminders.

Findings: The completion rate was 6.9% (329 of 4770). The majority (86.6% and 75.7%, respectively) highly rated the importance of nutrition during pregnancy and the significance of their role in nutrition education. Midwives’ nutrition knowledge was inadequate in several areas, such as weight gain, dairy serves and iodine requirements (73.3%, 73.2% and 79.9% incorrect responses, respectively). The level of confidence in discussing general and specific nutrition issues ranged mostly from moderate to low. The majority of the midwives (93%) provided nutrition advice to pregnant women. This advice was mostly described as ‘general’ and focused on general nutrition topics. Only half of the midwives reported receiving nutrition education during midwifery education (51.1%) or after registration (54.1%).

Conclusion: Australian midwives’ attitudes towards nutrition during pregnancy and their role in educating pregnant women about it were positive but their knowledge and confidence did not align with these attitudes. This could be due to minimal nutrition education during midwifery education or during practice. Continued education to improve midwives’ nutrition knowledge and confidence is essential.

Key words: Nutrition, knowledge, pregnancy, midwifery, education.

58

4.3 Summary of relevance Problem or Issue: Poor prenatal nutrition is linked to negative short and long term maternal and foetal outcomes. Pregnant women do not meet dietary recommendations and may not receive effective nutrition education. Australian midwives are well positioned to provide nutrition education to pregnant women but their knowledge of nutrition and confidence to provide nutrition education have not been reported.

What is Already Known: International research has reported positive attitudes of midwives towards nutrition during pregnancy but limited knowledge, confidence, and nutrition education.

What this Paper Adds: Evidence that Australian midwives have positive attitudes towards nutrition during pregnancy but inadequate nutrition knowledge and variable confidence, possibly due to not receiving nutrition education themselves, either before or after registration.

59

4.4 Introduction It is increasingly recognised that maternal nutrition during pregnancy affects the health of the mother and the baby. Suboptimal nutrition during pregnancy has been linked to excess gestational weight gain (Uusitalo et al. 2009). Excess gestational weight gain and maternal obesity are associated with a greater risk of adverse maternal and foetal outcomes, such as gestational diabetes, gestational hypertension, pre-eclampsia, caesarean delivery, high retention of postpartum weight, depression, low rates of breastfeeding, still births and perinatal deaths, birth defects, neonatal care admission, and macrosomia in addition to increased risk of developing childhood obesity and chronic diseases later in life (Guelinckx et al. 2008, Langford et al. 2011, Marchi et al. 2015).

The most recent national Australian data reported that the majority of Australian women do not meet Australian dietary recommendations despite perceiving their diet to be healthy (Malek et al. 2016). Pregnancy has been suggested as an influential ‘teachable moment’ to promote healthy nutrition (Phelan 2010). Pregnant women usually have contact with health care providers, and they tend to be more interested in, and actively seeking, nutrition information (Szwajcer et al. 2008). However, a recent review identified that limited nutrition education is often provided to pregnant women within antenatal care settings in developed countries (including Australia), despite health care providers (including midwives) acknowledging its importance (Lucas et al. 2014a). Inadequate time, resources and education were identified by health care providers as barriers towards the provision of nutrition education during pregnancy (Lucas et al. 2014a) .

In Australia, midwives are key providers of primary antenatal care. The Australian College of Midwives’ (ACM) philosophy acknowledges midwifery as a women-centred profession, which is based on a relationship between women and their midwives, and has the ability to affect the health and wellbeing of the mothers and the society in a positive way (Australian College of Midwives 2004). Through the provision of antenatal care, midwives work with women and support them in making informed decisions that can impact positively on their health and the health of their babies.

In the Essential Competencies for Basic Midwifery Practice of the International Confederation of Midwives (ICM) (International Confederation of Midwives 2010), it is indicated that midwives should have knowledge of maternal and foetal nutritional requirements, and the skills to assess maternal status and provide advice accordingly. The

60

Australian National Competency Standards also indicate that midwives have a public health role that encompasses the promotion of wellness of women, their families and the community, although the case of nutrition is not specifically addressed (Australian Nursing and Midwifery Council 2006). This places expectations on midwives to be knowledgeable about nutrition during pregnancy, and to have a role in the provision of nutrition education to pregnant women.

Clinical guidelines for antenatal care in Australia have been set to provide standard guidance for all health care providers involved in the provision of antenatal care (including midwives). The Australian National Antenatal Care Guidelines Module One was published in December 2012 (Australian Health Ministers’ Advisory Council 2012), followed by Module Two in 2014 (Australian Health Ministers’ Advisory Council 2014). The guidelines cover the provision of nutrition guidance to pregnant women, advice on supplements, and the management of nutrition related issues, such as nausea and vomiting.

A review investigating the role of midwives in nutrition education in developed countries (including Australia) reported midwives’ agreement on the importance of nutrition during pregnancy, and their significant role in educating women about it. However, it also reported that midwives’ nutrition knowledge was inadequate (Arrish et al. 2014). This review highlighted midwives’ lack of confidence in discussing some nutrition related issues, such as vegetarian diets, diets of women from different religions or backgrounds, and diets of women with previous medical conditions, such as gestational diabetes (Arrish et al. 2014). In some Australian qualitative studies, midwives pointed out they are main providers of nutrition advice, however, they lack confidence and communication skills in approaching sensitive topics such as weight management and obesity (Schmied et al. 2011, Willcox et al. 2012).

Currently, there are limited published quantitative data about the nutrition knowledge of Australian midwives, their attitudes towards the importance of nutrition during pregnancy, and their views of their role in providing nutrition education to pregnant women, and their confidence in discussing general and specific nutrition related issues. This study aimed to address this gap.

4.5 Methods

4.5.1 Design

The design of the research was a cross-sectional study using a web-based survey.

61

4.5.2 Research questions

1. What are midwives’ attitudes towards nutrition during pregnancy and their role in educating pregnant women about nutrition?

2. What do Australian midwives know about general nutrition during pregnancy?

3. What are the factors associated with midwives’ general knowledge of nutrition during pregnancy?

4. How confident do midwives feel in providing general and specific nutrition related advice?

5. Are dietitians’ services available for midwives and do midwives refer to dietitians?

4.5.3 Sampling and administration

A convenience sample of members of the Australian College of Midwives (ACM) was recruited for this study. Recruitment occurred through placing an invitation with a link to the survey in the ACM newsletter, and an invitation email via the ACM office to its 4770 members in August 2012, followed by two email reminders sent at monthly intervals. The first page of the online survey was an information sheet and consent statement. Respondents implied their consent by accessing and completing the web survey. A sample size calculation was attempted to estimate the minimum number of respondents required to have sufficient statistical power. The estimated minimum sample size required was 356. The calculation was based on a total population of 4770, margin error of 5 and a confidence level of 95% (Raosoft 2004).

4.5.4 Survey development

The survey used in the study was developed by the researchers based on previous literature (Mulliner et al. 1995, Barrowclough and Ford 2001, Elias and Green 2007) and the key issues related to nutrition in pregnancy. Two dietitians and two academics (from public health nutrition and midwifery) reviewed the survey. Further consultation with a professional statistician was sought before commencing data collection to confirm the appropriateness of the survey design to achieve the aims of the study. The survey was first piloted with five colleague researchers and then with five practising midwives. Necessary modifications, such as adding a few questions, modifying existing ones, and reducing ambiguity, were

62 undertaken. The survey was created online using Survey Monkey Software (SurveyMonkey Inc. Palo Alto, California, USA. www.surveymonkey.com).

4.5.5 Survey structure

The survey included four main sections:

4.5.5.1 Section 1: Nutrition education Respondents were asked whether they received nutrition information or education during their midwifery education and after registration as midwives. Questions also covered details of this education but these data will be reported elsewhere.

4.5.5.2 Section 2: Attitudes and confidence towards the provision of nutrition education during pregnancy In this section, respondents were asked to rate, using five-point scales, the importance of nutrition during pregnancy (‘very important’, ‘moderately important’, ‘important’, ‘slightly important’ and ‘not important at all’) and their role in providing nutrition education to pregnant women (‘very significant’, ‘moderately significant’, ‘significant’, ‘slightly significant’, ‘not at all significant’). They were also asked whether they provide nutrition advice to pregnant women and if so: to rate how confident they feel in discussing general or specific nutrition issues with pregnant women (for example, ‘very confident’, ‘moderately confident’, ‘confident’, ‘slightly confident’ and ‘not at all confident’); when they discuss these issues; and what sources they usually use as the basis of this advice. Their thoughts about receiving more nutrition information or education and having specific guidelines tailored to the nutrition education needs of midwives were also explored and will be presented elsewhere.

4.5.5.3 Section 3: Pregnancy general nutrition knowledge Twelve items were included to determine the respondents’ general knowledge of nutrition during pregnancy. Two main types of items were included: single-answer items (n = 8) and multiple-answer items (n = 4). The single-answer items included questions about the respondents’ knowledge of: average change in energy requirements during pregnancy; if there is a difference in the energy requirements for pregnant women during the three trimesters of pregnancy; the range of healthy weight gain during pregnancy for a woman who commenced her pregnancy at normal weight ; the most important vitamin supplement for vegetarian pregnant women; when women should take folic acid supplement 63 and the amount of folic acid supplement needed daily during pregnancy; the recommended number of serves of dairy foods required per day to meet pregnant women’s requirements for calcium; and iodine requirements per day for a pregnant woman.

The four multiple-answer items included questions about: foods that should be avoided in pregnancy as a risk of listeria; food sources of iron; advice to minimise the effect of nausea and vomiting during pregnancy; and foods to assist with resolving constipation during pregnancy. The respondents were instructed to choose the correct answer from the given options. The ‘I do not know’ option was added to prevent guessing when the respondents were not sure of their answers and was coded as ‘incorrect’ answer in the statistical analysis (Sarmugam et al. 2014).

Each single-item question had one correct answer and was given a score of one for each correct answer, giving them a total score of eight. Multiple-answer items had more than one correct answer and a score of one was given to each correct answer in each question, giving them a score of 12. The answers to the multiple-answer items were independent of each other. If the question had three correct answers, the respondent obtained a score of three out of three if all correct answers were chosen, and two out of three if two correct answers were chosen and so on. An overall score of 20 was given to the knowledge section combining the score of the single and multiple answer items.

4.5.5.4 Section 4: Demographic characteristics This section of the survey collected demographic data of the respondents including their gender, age category, midwifery education, years of experience, and principal state or territory of work. The survey was designed for and promoted as being for practising midwives who are actively involved in providing antenatal care either in hospitals or independently; therefore, respondents were asked to indicate their place of practice, level of maternity services and areas of maternity practice.

4.5.6 Data analysis

Data from the survey were analysed using the Statistical Package of the Social Sciences Software (SPSS) version 22 (Armonk, NY: IBM Corp.). Descriptive statistics were used to summarise the data. The effect of demographic characteristics on midwives’ knowledge was assessed using bivariate analyses, such as independent t test (for variables with two categories) and one-way ANOVA (for variables with more than two categories). Multiple

64 regression analysis was used to explain the variance in nutrition knowledge. Significant differences were identified at P < 0.05. The ‘I do not recall’ option in the two questions about whether midwives received nutrition education during midwifery education or after their registration was combined with the ‘No’ option in the independent t test and multiple regression analysis. All eight Australian states were listed in the original survey. However, due to small numbers of respondents from some states and for analysis purposes, the eight states were combined into three categories (New South Wales, Queensland, and Other). The category ‘Other’ included: South Australia, Tasmania, Victoria, Western Australia, Australian Capital Territory and Northern Territory. Likewise, the five-point scales (for example, ‘very confident’, ‘moderately confident’, ‘confident’, ‘slightly confident’ and ‘not at all confident’) were reduced to three categories (‘high confidence’ (including, ‘very confident’), ‘moderate confidence’ (combining ‘moderately confident’ and ‘confident’) and ‘low confidence’ (combining ‘slightly confident’ and ‘not at all confident’). This combination reflected further consideration of the terms used in the scale, as it was unclear how the participants may have interpreted ‘moderately confident’ and ‘confident’, and thus the responses to these two terms were combined. Spaces were provided for some questions to enable respondents to elaborate on their answers or provide further information. The data provided within these spaces were analysed using content analysis (Elo and Kyngas 2008).

4.5.7 Ethical approval

The study obtained ethical approval from the University of Wollongong and Illawarra Shoalhaven Local Health District Health and Medical Human Research Ethics Committee (HREC) (HE12/009, 5th of April, 2012).

4.6 Findings

4.6.1 Demographic characteristics

Of the 4770 members of the Australian College of Midwives, 393 midwives responded to the survey and 329 fully completed it and were included in the final analysis. Excluded were: one hard copy response from the pilot phase, the first electronic response because of a problem in the setting up of the survey, 61 incomplete surveys, and 1 duplicate.

The demographic characteristics of the respondents are shown in Table 4.1. Only four respondents were males. Approximately, three quarters of the midwives (74.8%, n = 246) were aged 41 and older and 69.6 % (n = 229) had work experience of more than 10 years.

65 Midwives from New South Wales and Queensland represented 52.9% (n = 174) of the respondents. Slightly more than half of the midwives (53.2%, n = 175) gained their midwifery education through hospital-based training. In the ‘other, please specify’ space, 33.7% of the midwives (n = 111) reported having additional qualifications, with midwifery and nursing related qualifications being the most frequently reported. The majority of the midwives worked in public hospitals (86.6%, n = 285) and 67.7% (n = 223) worked in regional and territory referral hospitals. In terms of areas of midwifery practice, 41.3% (n = 136) of the midwives rotated through antenatal, birthing suite and postnatal areas; and 29.2% (n = 96) worked either in antenatal care only or worked in antenatal care and birth suite or antenatal care and postnatal but did not rotate through all areas.

4.6.2 Attitudes of midwives towards the importance of nutrition and their role in providing nutrition education during pregnancy

Table 4.2 shows the attitudes of midwives towards the importance of nutrition during pregnancy and their role in educating women about it. When asked about the importance of nutrition during pregnancy, 86.6% (n = 285) of the midwives thought it was of high importance while 13.4% (n = 44) thought it was of moderate importance. Three quarters of the midwives (75.7%, n = 249) considered the role they can play in providing nutrition education for pregnant women to be of high significance, while 23.7% (n = 78) considered its significance as moderate. Only 0.6% (n = 2) considered their role to be of a low significance.

4.6.3 The provision of nutrition related advice by midwives and their confidence in discussing general and specific nutrition related issues

The provision of nutrition related-advice to pregnant women by midwives in the study is shown in Table 4.3. The majority of the respondents provided nutrition advice to pregnant women (93%, n = 306). The pattern of engaging with pregnant women in discussing nutrition issues for those midwives tended to take place at the first antenatal visit for most of the respondents (71.6%, n = 219) and less than half of the midwives provided nutrition advice at every antenatal visit (47.4%, n = 145). Nearly sixty per cent (59.5%, n = 182) discussed nutrition only when the woman had a medical condition requiring nutrition intervention, such as gestational diabetes. The three information sources most used by the midwives as the basis of their nutrition advice were other health professionals, such as dietitians (81.4%, n = 249), followed by general knowledge (75.5%, n = 231), and midwifery education (62.7%, n =192).

66 Table 4.1: Characteristics of the respondents Characteristics Number of responses (n)a Percentage (%) Gender Female 325 98.8 Male 4 1.2 Age 21–30 years 28 8.5 31–40 years 55 16.7 41–50 years 95 28.9 Older than 50 years 151 45.9 Education Bachelor degree of Midwifery 74 22.5 Hospital-based training Midwifery 175 53.2 Initial midwifery postgraduate degree 80 24.3 Years of experience Less than 2 years 22 6.7 2–5 years 30 9.1 6–10 years 48 14.6 More than 10 years 229 69.6 Principal state or territory of work New South Wales (NSW) 96 29.2 Queensland (QLD) 78 23.7 South Australia (SA) 30 9.1 Tasmania (TAS) 8 2.4 Victoria (VIC) 58 17.6 Western Australia (WA) 40 12.2 Australian Capital Territory (ACT) 8 2.4 Northern Territory (NT) 11 3.3 Principal place of practice Public hospital 285 86.6 Private hospital 16 4.9 Independent midwifery practice 28 8.5 Level of maternity services Community 53 16.1 Rural hospital 53 16.1 Regional hospital 113 34.3 Tertiary referral 110 33.4 Area of midwifery practiceb Antenatal care 96 29.2 Birthing (labour) suite 54 16.4 Postnatal 89 27.1 Rotation through all the above areas 136 41.3 Group practice (case load or team midwifery) 67 20.4 Independent midwifery practice 28 8.5 a Total number = 329. b Multiple responses allowed.

67 Table 4.2: Attitudes of midwives towards the importance of nutrition and their role in providing nutrition education during pregnancy The question High Moderate Low importance importance importance n a (%) How important do you think nutrition 285 (86.6) 44 (13.4) – is during pregnancy?

High Moderate Low significance significance significance How would you rate the role that 249 (75.7) 78 (23.7) 2 (0.6) midwives can play in providing nutrition information or education for pregnant women? a Total number = 329.

Midwives who answered ‘yes’ (n = 306) to the question about the provision of nutrition advice were asked to specify the nutrition advice they provided and 83.3% (n = 255) of those midwives included written information.

Content of the advice: The three most frequent topics midwives provided nutrition advice about were: healthy eating, micronutrients, and food safety. Recommended weight gain/weight management, advice related to the management of common pregnancy discomfort (e.g., nausea and vomiting, indigestion, heart burn and constipation), nutrition for diabetes management/prevention, nutrition for breastfeeding, and alcohol were specified less frequently. The least mentioned topics by midwives were fluid intake, coffee, and vegetarian diet. Micronutrients advice varied as well; the most frequently mentioned micronutrient was iron, followed by and calcium. Iodine and vitamin D were less frequently mentioned. The least mentioned nutrients were vitamin B12, fish oil, magnesium, and zinc. Some midwives referred to providing advice about micronutrients without any specification.

Type of the advice: Midwives frequently referred to the nutrition advice or information they provided as ‘general’ or ‘basic’, for example:

Very basic advice on well-balanced diet and the foods to avoid during pregnancy. (MW242)

68 Table 4.3: Provision of nutrition related-advice to pregnant women by midwives in the study and the availability of dietitians’ services and conditions for referral

n % Do you provide any nutrition-related advice to pregnant women?a Yes 306 93.0 No 23 7.0 On what occasions do you discuss nutrition issues with pregnant women?b,e At the first antenatal visit 219 71.6 If the pregnant woman has a medical condition requiring nutrition 182 59.5 intervention, such as gestational diabetes At every antenatal visit 145 47.4 Only when the pregnant woman asks questions 72 23.5 I only rarely discuss nutrition issues with pregnant women 16 5.2 What information sources do you use as the basis for this advice?b,e Other health professionals, such as dietitians 249 81.4 General knowledge 231 75.5 Midwifery education 192 62.7 Governmental or official websites 165 53.9 Midwifery journals 161 52.6 Textbooks 119 38.9 Internet 110 35.9 Otherc 49 16.0 Media (e.g., Television, newspaper) 23 7.5 Magazines 16 5.2 Do you have a dietitian’s services or support for pregnant women at your hospital?a Yes 274 83.3 No 55 16.7 If yes do you make referrals to the dietitian?d Yes 243 88.7 No 31 11.3 a n = 329. b n = 306 (Number varies from total number because only midwives who provide nutrition-related advice answered this section). c Other sources included: other scientific, medical , naturopathic and diabetes journals, booklets from hospitals or dietitians, governmental handouts, clinical guidelines, policies and protocols, midwives’ personal lifestyle, personal experience with dietitians and alternative health professionals such as naturopaths and herbalists, nutrition or complementary medicine and naturopathic courses, workshops, books, the gym, and nutrition readings. d n = 274 (only midwives who had dietitian’s support or services answered this question). e Multiple responses allowed.

‘Specific’ advice was also frequently indicated. It referred to either topics midwives focused on when providing nutrition advice or advice that was only directed to pregnant women with specific issues, such as obesity, diabetes or following special diets such as vegetarian or vegan.

69 Eat a healthy, fresh and balanced diet. And give more specific advice for i.e. anaemia, morning sickness, constipation, indigestion etc. (MW146)

Midwives also indicated they provided general advice to all pregnant women and referred those with specific issues to dietitians. A few midwives (n = 10) provided specific advice that fitted the context of care they provided or was related to other roles they undertook, such as working with women from indigenous backgrounds or with gestational diabetes.

Extent and approach of the advice: The extent of topics covered by midwives within their nutrition advice varied. The topics ranged from one topic to several topics. Midwives either included details of how they provided nutrition advice, or were ambiguous and wrote general comments. A small number of the midwives specified they discussed women’s current diets (n = 10), individualised their advice (n = 7), or provided culturally sensitive advice (n = 6). Few midwives (n = 5) indicated that they only provided advice if women asked them or if there was a concern or a problem.

Midwives (n = 16) either indicated the use of brochures to enhance the provision of nutrition advice or perceived the provision of brochures alone as sufficient for general nutrition advice.

I give them the booklets and handouts related to nutrition that cover most things and then discuss specific things related to their needs... (MW81)

Midwives (n = 8) included comments on barriers that might affect the provision of nutrition advice such as: limited time, limited resources, limited availability of further education, model of care, and difficulties in communicating with obese women about nutrition.

4.6.4 Pregnancy general nutrition knowledge

Table 4.4 displays the distribution of correct and incorrect responses to the knowledge questions for both single and multiple-answer items. The single answer nutrition knowledge question with the highest percentage of correct answers (93.6%, n = 308) was when women should take folic acid supplement. A large proportion of the respondents also chose the correct answers for the questions about: the amount of folic acid supplement needed daily during pregnancy; if there was a difference in the energy requirements for pregnant women during the three trimesters of pregnancy; and the most important vitamin supplement for vegetarian pregnant women (67.5%, 63.8%and 62.3%, respectively). Half (50.5%, n = 166) of the midwives provided incorrect answers to the qu-

70 estion about average change in energy requirements during pregnancy. The questions with the least correct answers were: the range of healthy weight gain during pregnancy for a woman who commenced her pregnancy at normal weight; the daily recommended number of serves of dairy foods, and iodine requirements per day for a pregnant woman (73.3%, 73.2% and 79.9% incorrect responses, respectively). Two comments were also included that questioned official dietary advice, for example the following negative comment relating to the daily recommended number of serves of dairy foods to meet pregnant women’s needs for calcium. I preferred not to answer the Q [question] about how many serves of dairy to give adequate calcium ̶ because I don't believe dairy is healthy for anyone. (MW167) For multiple-answer questions (Table 4.4), the question about foods to assist with resolving constipation during pregnancy was answered correctly by the majority of the respondents (94.8%, n = 312) who ticked both correct options. Almost two thirds of the respondents (63.8%, n = 210) were able to tick all the correct answers for the advice to minimise the effect of nausea and vomiting during pregnancy. In regard to foods that should be avoided as a risk for listeria in pregnancy, the foods were highly recognised individually and 77.8% (n = 256) of the respondents chose all the correct answers. In terms of food sources of iron, only 59% (n = 194) and 11.2% (n = 37), respectively of the midwives recognised legumes and seafood as sources of iron and only 9.1% (n = 30) of the respondents ticked all the correct answers.

The mean of the total score was 13.64 out of possible 20 (± SD 2.04). The minimum score was 7 and maximum score was 18. In terms of the significant difference between the means of the groups: higher scores were achieved by midwives in independent midwifery practice (M = 14.75, SD = 1.94) compared to those working in public hospitals (M = 13.54, SD = 2.04, P = 0.010); in regional hospitals (M = 13.96, SD = 1.94) compared to those working in rural hospitals (M = 12.92, SD = 2.18, P = 0.025); by those who reported receiving nutrition information or education during their midwifery education (M = 13.96, SD = 2.01) compared to midwives who did not (M = 13.30, SD = 2.03, P = 0.003); and by those who reported high level of confidence (M = 14.48, SD = 1.90 ) in providing general related nutrition advice compared to those who reported moderate (M = 13.70, SD = 2.01) and low levels of confidence (M = 13.15, SD = 1.94, P = .006). In the multiple regression analysis, these significant variables were entered simultaneously into the model (n = 306). All variables had independent significant effects on nutrition knowledge scores apart from level of maternity

71 services which approached the significant level (P = 0.06). The model accounted for a significant 7% of the variability in midwives’ nutrition knowledge scores (R2 = .077, adjusted R2 = .065, F (4, 301) = 6.320, P = 0.000).

4.6.5 Nutrition education

Slightly over half (51.1%, n = 168) of the midwives in the study reported they had received nutrition information or education during their midwifery education, while 28% (n = 92) said ‘No’, and 21% (n = 69) did not recall receiving this education. Similarly, slightly over half (54.1%, n = 178) reported they received nutrition education after being registered as a midwife, while 42.2% (n = 139) said ‘No’, and 3.6% (n = 12) did not recall receiving this education.

4.6.6 Confidence in providing general and specific nutrition related advice

The level of confidence of midwives in providing general and specific nutrition-related advice to pregnant women is presented in Table 4.5. The majority of the midwives (70.9%, n = 217) had a moderate level of confidence in providing ‘general-related nutrition advice’ to pregnant women. In terms of specific nutrition issues, the level of confidence ranged from moderate to low. Midwives had a moderate level of confidence in discussing ‘weight gain and obesity’, ‘nutrition for breastfeeding’, ‘providing advice on vitamins’, and ‘diabetes’. The areas where midwives had a low level of confidence were: discussing vegetarian diets, vegan diets, diets of women with previous or complex medical conditions, and diets of women from ethnic or minority groups.

4.6.7 Availability of dietitians’ services and referral to dietitians

The availability of dietitians’ services and referral to dietitians are exhibited in Table 4.3. Dietitians’ services or support were available for 83.3% (n = 274) of the respondents and of those 88.7% (n = 243) made referrals to the dietitians. Midwives were asked if they reported making referrals to the dietitians to specify for what conditions; 188 midwives provided answers to this question. The most common conditions for which referrals to dietitians were made were diabetes and obesity. Other weight related issues (inadequate/excessive weight gain, , and ), complex medical conditions, and dietary concerns were mentioned less frequently. The least mentioned conditions were common symptoms of pregnancy (morning sickness, anaemia, and constipation), special diets (for example, vegetarian/vegan) and others such as women’s requests.

72 Although dietetic services or support were indicated as available and used by the majority of midwives, the midwives (both those who do and do not make referrals) provided comments that indicated issues around accessing these services. The most common issue was that referral is predominately restricted to women with gestational diabetes. Other issues included: high demand for dietitians’ services, limited time allocations, limited funds for full time staff, limited availability of dietitians in remote areas, and lack of time for midwives to make referral to dietitians.

4.7 Discussion This study reports on five key areas relating to the provision of nutrition education by Australian midwives. The majority of the Australian midwives in this study highly rated the importance of nutrition during pregnancy and the significance of their role in providing nutrition education. They reported providing nutrition advice to pregnant women, mainly focussing on topics such as healthy eating, micronutrients, and food safety; however, their general knowledge of nutrition was found to be inadequate in a number of areas. Their low level of knowledge was not unexpected, as only half of the midwives reported receiving nutrition information or education during their midwifery education or during practice. Most of the midwives had a moderate level of confidence in providing a range of nutrition advice to pregnant women but were not so confident in discussing special diets. For complex issues, such as diabetes and obesity, the midwives referred women to dietitians but there were a number of barriers limiting referral for other nutrition related issues.

The high rating by the majority of midwives of the importance of nutrition during pregnancy and the significance of their role in nutrition education is similar to previous findings (Elias and Green 2007). However, these positive views did not align with the midwives’ own knowledge of general nutrition during pregnancy, which was overall inadequate. Prior studies have also found midwives’ knowledge of nutrition to be inadequate (Mulliner et al. 1995, Barrowclough and Ford 2001, Symon 2002). A contrary finding has been reported by Elias and Green (2007) who found New Zealand midwives to be knowledgeable of nutrition and highly confident in educating pregnant women about it. A possible explanation is that in New Zealand midwives are the Leading Maternity Carers who provide continuity of care for the vast majority of women during pregnancy (Ministry of Health 2015). For this reason, they might be more proactive in learning about nutrition and they may perceive it as their role to educate women about nutrition. Similarly, in our study midwives in independent

73 Table 4.4: The distribution of correct and incorrect/do not know answers of the knowledge questions (single-answer items and multiple-answer items)

74 Table 4.5: Level of confidence of midwives in providing general and specific nutrition- related advice to pregnant women

midwifery practice had significantly higher mean scores of nutrition knowledge compared to midwives working in public hospitals. The use of different tools to evaluate midwives’ knowledge might be another explanation for the discrepancy in reported knowledge levels between Australian and New Zealand midwives.

The majority of the midwives in the study provided nutrition advice to pregnant women. This is similar to earlier research in the United Kingdom and New Zealand (Farrar 2013, Pan et al. 2014). The discussion of nutrition issues with pregnant women was reported to primarily take place at the first antenatal visit for the majority of midwives, which is in line with the Standards of Maternity Care of Australia and New Zealand (2014) (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014). Only about half of the midwives discussed nutrition at every antenatal visit. Discussing nutrition at every antenatal visit is a recommendation of the recent Australian Antenatal 75 Care Guidelines (Australian Health Ministers’ Advisory Council 2014). However, a possibility for this finding could be that only midwives who work in a continuity of care model are well placed to provide nutrition advice at every antenatal visit as they see pregnant women throughout their pregnancy. How to incorporate nutrition discussions into every antenatal visit, across all models of care, needs further examination.

Nearly 60 per cent of the midwives discussed nutrition with the woman only if she had a medical condition such as gestational diabetes. This finding was further confirmed through some midwives’ comments that they only provided specific advice to women with special issues (such as diabetes and obesity) or provided advice only if women asked them, or there was a concern. Although midwifery philosophy is based on viewing pregnancy and birth as normal events and promoting wellbeing (Australian College of Midwives 2004), the rising rates of obesity and diabetes might have shifted the focus of midwifery from promoting health and wellbeing to managing risks. Lack of time (reported previously (Lucas et al. 2014a) and pointed out by few midwives in this study) may also limit the extent of advice provided by midwives, and force them to prioritise advice given to nutrition related issues with perceived immediate risks and effects on the health of the mother and baby, such as gestational diabetes. Reemphasising midwives’ role in public health and wellness promotion within midwifery education and during practice as pointed out by the National Australian Competency Standards is crucial (Australian Nursing and Midwifery Council 2006), so midwives provide nutrition advice for all pregnant women and not only those with medical conditions such as gestational diabetes.

Midwives’ low level of knowledge of the average change in energy requirements during pregnancy (an increase by 1400–1900kJ /day) and the healthy weight gain for a woman who commenced her pregnancy at normal weight (11.5–16 kg) was of concern given the complications associated with excessive weight gain during pregnancy. On average there is only a slight increase in the energy requirements of pregnant women and thus emphasis should be placed on improving the quality of dietary intake rather than the quantity (Williamson 2006). Highlighting this piece of information to pregnant women might contribute to the prevention of excessive weight gain during pregnancy.

Midwives were found to lack knowledge of appropriate weight gain during pregnancy. Australia does not have specific weight gain guidelines.The Institute of Medicine guidelines are widely accepted and have been adopted as weight gain recommendations in Australia but

76 midwives did not appear to be aware of this. A recent Australian research study found that health care providers (including midwives) had low awareness of Institute of Medicine guidelines, with 25% not providing any gestational weight gain advice in accordance with pregnant women Body Mass Index (BMI) category (Wilkinson and Stapleton 2012). Failure to provide weight gain advice by health care providers has been linked to pregnant women gaining weight outside the recommendations of the Institute of Medicine guidelines (Cogswell et al. 1999).

Midwives varied in their knowledge of nutrient requirements during pregnancy. The timing of folic acid supplement was widely known (93.6% responded correctly), perhaps as a result of long-standing public health campaigns. However, 32.5% of the respondents answered incorrectly when asked about the amount of folic acid supplement needed daily during pregnancy. The level of professional knowledge of nutrient recommendations can be affected by inconsistencies in official guidance. In the case of recommended folic acid supplementation at the time of designing this study, the National Health and Medical Research Council’s (NHMRC) recommended dose for folic acid supplement during pregnancy was 400μg/day (National Health and Research Council 2006) ; therefore it was coded as the correct answer. However, at the time of collecting the data the National Antenatal Care Guidelines Module One had been released recommending a dose of 500μg/day (Australian Health Ministers’ Advisory Council 2012), even though the NHMRC recommendations continued to be 400μg/day. Both answers were then recorded as correct, but inconsistent official guidance will cause confusion, both in terms of health care providers and what advice they should be giving, and for women in terms of what advice to follow.

Midwives’ knowledge of vitamin B12 and iodine was low, perhaps due to lower levels of publicity as compared to other nutrients such as folic acid. The Standards of Maternity Care of Australia and New Zealand (2014) recommend that vegetarian and vegan pregnant women should be supplemented with vitamin B12 during pregnancy as they are at risk of vitamin B12 deficiency, which may lead to neurological adverse outcomes in the infants (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014). Midwives need to be aware of such recommendations to advise vegetarian and vegan pregnant women accordingly.

Iodine has a very important role in the development of the foetal brain and the nervous system and even mild deficiency during pregnancy can result in long term adverse outcomes

77 (Hynes et al. 2013). The NHMRC recommends pregnant women to have dietary intake of 220μg of iodine per day (National Health and Research Council 2006). NHMRC recommends also a supplementation of 150μg/day to all pregnant women to meet increased requirements that might not be met through diet alone (National Health and Medical Research Council 2010). Mild iodine deficiency among Australian pregnant women has been reported (Hynes et al. 2013). Pregnant women reported health care providers as their main source of information about iodine, but a small proportion received such advice (Martin et al. 2014). Midwives in this study also less frequently commented they provided advice on iodine compared to other nutrients, such as iron, folate, and calcium. Health care providers (including midwives) need to be aware of all aspects of knowledge related to iodine (for example, its importance in pregnancy, the increased requirements and necessity of supplementation) to educate pregnant women about them.

The questions of food related knowledge, such as the recommended number of serves of dairy per day, was answered poorly by the majority of the midwives. The correct answer at the time of the study was two serves per day where a serve equals: a glass of milk (250mL), a tub of yogurt (200g), or 2 slices of cheese (40g). The Australian dietary Guidelines were revised and published in 2013 (National Health and Medical Research Council 2013) and the recommended number of dairy serves was increased to two and a half serves per day, again reflecting evolving nutrition advice and reinforcing that health care providers need to be vigilant to ensure their levels of knowledge remains current. Two midwives in the study provided comments that questioned the nutritional role of dairy products. These responses reflected the respondents’ personal views, not the official, evidence-based dietary guidance that should inform their practice. Low levels of formal nutrition education and professional oversight of the nutrition education being provided may result in health care providers providing personal perspectives rather than evidence-based guidelines. The Australian Dietary Guidelines (National Health and Medical Research Council 2013) recommend dairy products as part of a balanced diet and an excellent source of calcium and many other important nutrients (reduced fat varieties are recommended). Other alternative sources for calcium are recommended for people who do not consume dairy.

Midwives identification of multiple food sources and multiple risky foods was varied, with most respondents highly recognising the answers individually but not ticking all correct answers. For example, foods that should be avoided because they pose a risk of listeria in pregnancy (i.e. soft cheeses, pre-prepared salads, and cold meats) were highly recognised

78 individually but not all respondents identified all three foods. Listeria is a food borne that can cause adverse effects on the health of the unborn baby (Swaminathan and Gerner- Smidt 2007), and midwives need to be aware of all foods that could carry the risk of listeria to educate pregnant women about them.

Regarding food sources of iron, although iron was the most frequent micronutrient midwives mentioned they provided advice about, only 59% recognised legumes and very few (11.2%) recognised seafood as good sources of iron. All pregnant women have increased requirements of iron, which might place them at increased risk of developing iron deficiency anaemia (Puolakka et al. 1980). Legumes are good sources of iron especially for vegetarian and vegan women who do not consume animal foods, and this information needs to be recognised by all midwives when advising vegetarian or vegan women.

The factors that had significant links to midwives’ nutrition knowledge in bivariate analyses included: nutrition education or information received during midwifery education, principal place of practice, level of maternity services, and confidence in providing general nutrition advice. Although nutrition education provided during midwifery education is insufficient on its own, it establishes basic knowledge and skills that midwives can build on during practice. Therefore, midwifery education needs to ensure that its nutrition content covers those basic knowledge and skills. The difference in knowledge levels between midwives working in public hospitals and independent midwives could be due to variance in models of care. Independent midwives provide continuity of care throughout pregnancy; they may be more active in acquiring nutrition knowledge as they may feel a high level of responsibility for the overall advice they provide to pregnant women. Public hospital antenatal care is provided by a variety of practitioners where midwives may not see the same women twice during pregnancy. Therefore, they may lack resources to either update their knowledge or provide nutrition advice to pregnant women. Midwives in rural hospitals also had lower knowledge compared to midwives in regional hospitals. This is not surprising as midwives in rural hospitals usually work in isolation and might not have the support of dietitians, which midwives in our study cited as the most used source of nutrition information. These results indicate a need for continuous education and updates for midwives in public hospitals, especially rural hospitals.

The significant factors combined (including: nutrition education or information received during midwifery education, principal place of practice, level of maternity services, and

79 confidence in providing general nutrition advice) explained 7% of the variation in midwives’ knowledge in the model of multiple regression. Although the proportion of variance is small, it is significant and needs to be taken into consideration. It is likely that there are other factors than those included in this exploratory study that exert greater impacts on midwives’ knowledge. Future studies would be needed to confirm our findings and also to identify further factors affecting midwives’ knowledge in greater depth.

The confidence level of most midwives ranged from moderate to low in discussing specific nutrition issues. These results were to some extent anticipated as they were comparable with earlier studies (Mulliner et al. 1995, Elias and Green 2007). The qualitative comments of midwives identified that topics such as weight gain/weight management, diabetes, and vegetarian/vegan diets were less frequently specified as part of nutrition advice provided by the midwives compared to general topics. In regard to ‘weight gain/obesity’, barriers such as perceived low priority of gestational weight gain, sensitivity of the issues for both midwives and pregnant women, lack of resources, education, and communication skills were also reported in the literature as affecting midwives’ ability to discuss these topics with pregnant women (Schmied et al. 2011, Willcox et al. 2012).

Another possible explanation for low level of confidence in discussing specific nutrition related issues is that some of these issues might be perceived by the midwives as out of their scope of knowledge and practice, and should be referred to dietitians who are the experts in the area of nutrition. However, as was identified from midwives’ comments in this study, referral to dietitians (for issues other than gestational diabetes and to a lesser extent obesity) is limited, mainly due to limited access to dietitians even if the referral was made. This is a health system issue that needs to be addressed, so midwives can confidently refer pregnant women with nutrition education needs out of their scope of knowledge to dietitians as required. Given the rising rates of obesity, it is vital that midwives are equipped to provide nutrition education and support to all pregnant women. Our study identified health professionals, such as dietitians, as the most frequently used source of nutrition advice for midwives; therefore, (with their current limited access to pregnant women), dietitians could contribute to enhancing maternal and foetal health by educating midwives via the provision of regular education sessions, updates and resources.

Midwives’ inadequate level of pregnancy general nutrition knowledge (in several areas) and moderate to low levels of confidence in discussing general and specific nutrition related

80 issues observed in this study could reflect that they had not received adequate nutrition information or education about these issues. Indeed, in this study, only half of the midwives reported receiving nutrition education during midwifery education and during practice. Midwives need to be equipped with adequate nutrition education both while obtaining their basic qualifications and during practice, if they are expected to discuss healthy nutrition with pregnant women as outlined in the new Antenatal Care Guidelines (Model One (Australian Health Ministers’ Advisory Council 2012) and Two (Australian Health Ministers’ Advisory Council 2014)), and fulfil their role in improving the health of mothers and future generations.

4.7.1 Limitations

A number of limitations of this study are identified. Not all Australian midwives had the opportunity to respond to the survey as not all Australian midwives are members of the ACM. The completion rate was 6.9% of the 4770 midwives but the number of respondents (n = 329) was very close to the estimated required sample size (n = 356) and provided sufficient power to detect statistical significance. The response rate was also comparable to previous research conducted with this group (Biro et al. 2013). Online surveys are known to have a significantly lower response rate compared to paper surveys (Yetter and Capaccioli 2010). The frame of convenience sampling of the study has some inherent limitations as midwives who chose to undertake the survey might have been more interested, motivated or knowledgeable about nutrition than the rest of the population. Recall bias cannot be totally excluded, especially in terms of receiving nutrition information or education during midwifery education, as three quarters of the responding midwives were aged 41 and older, and may have undertaken their midwifery education a long time ago. Some midwives also reported difficulty in listing everything they included in their advice. Taking into consideration the feedback from the piloting of the survey (that the survey was long), the knowledge part was kept short and general. It might have not been reflective of all aspects of nutrition during pregnancy.

Although the survey was meant for practising midwives, the emails were sent through the ACM officers and the researchers had no control over who responded to the invitations. It is possible that some of the respondents were not currently practising midwives. Therefore, these results cannot be generalised and need to be interpreted with caution. Nevertheless, the sample characteristics were similar to midwives’ workforce characteristics in 2012 in terms

81 of gender and age (Australian Institute of Health and Welfare 2013). This study, thus, highlights that the nutrition knowledge of this sample of mature Australian midwives appears to be inadequate in several areas and would benefit from further education and support.

4.7.2 Future research

A comprehensive validated survey examining midwives’ knowledge of Australian dietary guidelines (National Health and Medical Research Council 2013) is warranted. Midwives’ knowledge of and their adherence to the National Antenatal Care Guidelines would also benefit from further exploration (Australian Health Ministers’ Advisory Council 2012, Australian Health Ministers’ Advisory Council 2014). Semi-structured interviews are needed to gain in-depth understanding of midwives’ role and approaches in the provision of nutrition advice during pregnancy and barriers which might impact on this role.

4.8 Conclusion and practical implications Nutrition during pregnancy is important and midwives play a key role in providing nutrition education to pregnant women. However, the results of this study indicate that the opportunity to support women during this time may be lost due to low levels of knowledge, variable levels of confidence and passive approaches to nutrition education during antenatal visits. As nutrition education during midwives’ professional education was one of the significant links to nutrition knowledge levels, professional education requirements should be re-examined to bring them in line with evidence-based nutrition guidelines and clinical practice guidelines. Continued nutrition education to support midwives in practice (especially in public and rural hospitals) is equally important and could be provided through official organisations, such as the ACM, to ensure currency of midwives’ nutrition knowledge.

4.9 Conflict of interest The authors do not have any conflict of interest.

4.10 Acknowledgments and disclosures The authors would like to thank all the midwives who participated in the study. The authors express special thanks to Associate Professor Marijka Batterham for providing statistical advice. This study was part of a PhD scholarship for J. Arrish funded partly by the Libyan government. The Libyan government however, did not have any role in the study.

82

5 SELF REPORTED NUTRITION EDUCATION RECEIVED BY AUSTRALIAN MIDWIVES BEFORE AND AFTER REGISTRATION

5.1 Preface In the preceding chapter, a sample of Australian midwives (members of the ACM) was surveyed and found to have inadequate levels of general knowledge in the area of nutrition during pregnancy and variable levels of confidence in discussing general and specific nutrition issues with pregnant women. This was not unexpected as only half of the sample reported receiving nutrition education while obtaining their basic education or following their registration.

The content of this chapter presents the answers to the second research question of this thesis. It draws on data from the quantitative study of the practitioners’ arm (i.e. midwives) presented in Chapter 4. Midwives’ reception of nutrition education during basic education or during practice was investigated in the study using yes/no questions. The purpose of these questions was to assess the effect of the reception of nutrition education as a variable on midwives’ nutrition knowledge. The midwives who confirmed receipt of such education were asked to answer further questions about the details of this education. These questions were included to gain more insight into the types of nutrition education midwives received and to explore its adequacy to support them in their role in providing nutrition advice to pregnant women. The findings of this exploration are presented in this chapter. Identified gaps and implications for basic and continuing education are also discussed. Following in the next chapter, the content of the qualitative study of the practitioners’ arm will be presented.

Note: This chapter is a manuscript that was published in the Journal of Pregnancy (see Appendix C) and is presented as it was published with minor modifications in terms of formatting (such as figure and table numbering, and the referencing style) to ensure cohesion within the thesis and to conform to the University of Wollongong’s thesis guidelines

Citation: Arrish, J., Yeatman, H. and Williamson M. (2017). "Self-reported nutrition education received by Australian midwives before and after registration." Journal of Pregnancy. 17:5289592, p 9. DOI:10.1155/2017/5289592.

Authors’ contribution: J. Arrish has main responsibility for survey design, data acquisition, data analysis and interpretation, and writing, and submitting the manuscript. H. Yeatman and M. Williamson contributed to the conception of the study, design of the survey, and the development of the manuscript.

83 5.2 Abstract Educating midwives to provide nutrition advice is essential. Limited research focuses on midwives’ nutrition education. This paper explores self-reported nutrition education received by Australian midwives before and after registration. It draws on quantitative and qualitative data from a larger online survey conducted with the members of the Australian College of Midwives (response rate = 6.9%, n = 329). Descriptive and content analyses were used. Of the midwives, 79.3% (n = 261) reported receiving some nutrition education during, before and/or after registration. However, some described this coverage as limited. It lacked sufficient focus on topics such as weight management, nutrition assessment, and nutrition for vulnerable groups. Continuing education often occurred through personal initiatives, such as the midwife enrolling in external courses or exploring issues on the Internet and with colleagues. The majority of participants indicated a need for increased nutrition education (94.2%, n = 310) and guidelines tailored for them to provide nutrition advice (87.8%, n = 289). Australian midwives may not be receiving adequate nutrition education to provide nutrition advice. Inclusion of evidence-based nutrition components in midwifery education and regular updates for practising midwives focusing on challenging nutrition issues is required to ensure that they are supported in this important role.

Key words: Nutrition; education; pregnancy; midwifery.

84 5.3 Introduction Accumulating research points to links between prenatal diet and maternal and foetal health. Observational studies have identified an association between healthy diet during pregnancy and reduced gestational weight gain and lower risk of pregnancy complications such as preterm birth, pre-eclampsia, and reduced foetal growth (Brantsæter et al. 2014). Pregnant women have increased requirements for some nutrients such as folic acid (Williamson 2006) and iodine (National Health and Medical Research Council 2010) that might not be obtained from diet alone and supplementation is recommended. Other important aspects of maternal diet during pregnancy include: appropriate weight gain and weight management, food safety, and management of pregnancy symptoms such as nausea and vomiting, constipation, and heartburn. The importance of nutrition during pregnancy and the importance of nutrition support as a component of antenatal care have recently been reinforced by the World Health Organization (World Health Organisation 2016).

Pregnant women are considered more accepting of nutrition advice (Szwajcer et al. 2009). May et al. (2014) found positive changes in the dietary behaviour of pregnant women who were provided nutrition advice by their health care professionals compared to those who were not. Yet the provision of nutrition advice by health professionals to pregnant women is limited, with lack of practitioner education being indicated as one of the obstacles to the provision of such advice (Lucas et al. 2014a). Research has reported that nutrition education received by doctors is inadequate (Adams et al. 2006, Adams et al. 2015); however, midwives’ nutrition education has received little attention.

Midwives are one of the primary care providers of in Australia. Midwives have been reported as the most frequent source of health information for Australian pregnant women (Grimes et al. 2014) and their role in the provision of nutrition advice is clearly defined in the International Confederation of Midwives Essential Competencies (International Confederation of Midwives 2010). However, midwives seem to lack adequate nutrition knowledge and skills (Arrish et al. 2014). This may be attributed to inadequate education provided in midwifery courses (Arrish et al. 2014). Previous research in the United Kingdom and Australia indicated midwives’ lack of education on some topics such as obesity and weight management (Lee et al. 2012, Willcox et al. 2012, Heslehurst et al. 2013, Wilkinson et al. 2013) or healthy eating (Lee et al. 2012). Prior Australian research also identified that health professionals (including midwives) need continuing professional education about nutrition during pregnancy and breastfeeding (Hughes et al. 2011). 85 A recent Australian study investigating nutrition education within midwifery programmes using a mixed-methods approach incorporating online surveys and interviews with the course coordinators of the programmes identified some gaps (Arrish et al. 2016b). Although all surveyed programmes included nutrition content within their curricula, topics taught varied, and the number of total hours was low. The education seemed to be medically oriented and lacked focus on developing nutrition assessment skills or practical nutrition training (Arrish et al. 2016b). Additionally, a review investigating online opportunities for professional development in nutrition in Australia identified the scarcity of such opportunities and various gaps within those available (State of Queensland Queensland Health 2015).

The aim of this study was to explore Australian midwives’ recollections of the nutrition education they received during basic education and following registration and their perspectives regarding their preparation to provide nutrition advice.

5.4 Methods

5.4.1 Design

The study used a cross-sectional descriptive design.

5.4.2 Participants and distribution

The members of the Australian College of Midwives (ACM) were invited in 2012 (n = 4770) to participate in the study through an invitation published in the ACM newsletter and an email invitation sent through the ACM office. The invitations contained a hyperlink to the survey. Two email reminders were subsequently sent at one month intervals. The survey included an information sheet explaining the purpose of the study and a statement indicating that the participants provided their consent if they completed the survey. A power calculation was undertaken, providing an estimated minimum sample size of 356, based on a total population of 4770, margin error of 5, and a confidence level of 95%.

5.4.3 Survey development

Previous literature (Mulliner et al. 1995, Barrowclough and Ford 2001, Elias and Green 2007) was drawn upon to develop the survey instrument. Five experts, including two dietitians, two academics (with expertise in public health nutrition and midwifery), and a statistician, reviewed the survey. The survey was circulated to five research colleagues and

86 five practising midwives as a pilot. The survey was consequently modified prior to dissemination. Survey Monkey Software was used to create the final format online (Survey Monkey Inc., Palo Alto, California, USA, www.surveymonkey.com). The full survey examined midwives’ provision of nutrition advice during pregnancy, their knowledge, attitudes, and confidence in this area (Arrish et al. 2016a). The survey results indicated that 93% of the midwives provide nutrition advice to pregnant women but their nutrition knowledge and confidence in providing general and specific nutrition-related advice were inadequate. Therefore, more focus needs to be directed to nutrition education received by midwives (Arrish et al. 2016a).

5.4.4 Survey items

This paper reports on the seven questions related to nutrition education received by midwives during midwifery education and/or during practice. The first two questions included open- ended components. Participants were asked if they received nutrition education and if yes, to report the number of hours, number of sessions provided, and where they were provided. Participants who answered ‘yes’ to one or both of the questions also were directed to provide the details of this education (including information on who provided it and the nutrition topics covered) from a drop down menu. Midwives’ views were sought on receiving more nutrition education and having guidelines tailored for them to provide nutrition advice, as well as the reasons for such views. Eight demographic questions were included (gender, age, midwifery education, years of experience, place of practice, principal state/territory of work, level of maternity services, and areas of maternity practice).

5.4.5 Analysis

The Statistical Package for the Social Sciences Software (SPSS) version 22 (Armonk, NY: IBM Corp.) was used to report the quantitative data. Descriptive data were presented using frequencies and percentages. Participants provided additional information via text boxes. This was analysed in a descriptive manner using content analysis (Elo and Kyngas 2008).

5.4.6 Ethical approval

The University of Wollongong Health and Medical Human Research Ethics Committee (HE12/009) granted ethical approval for the study and it was carried out in accordance with The Code of Ethics of the Declaration of Helsinki (World Medical Association 2013).

87

5.5 Results There were 393 responses, 64 of which were excluded (61 for missing data, one a duplicate, one response from the pilot, and one electronic), resulting in 329 complete surveys for analysis (final response rate of 6.9%, 329 of 4770). Table 5.1 shows the participants’ demographics. The majority were: female (98.8%, n = 325), more than 50 years of age (45.9%, n = 151), employed for over 10 years (69.6 %, n = 229), and resident in New South Wales and Queensland (52.9%, n = 174), had hospital-based midwifery training (53.2%, n = 175), and were employed in public hospitals (86.6%, n = 285) generally in regional and territory referral hospitals (67.7%, n = 223) rotating through antenatal, birthing and postnatal areas (41.3%, n = 136).

Of the 329 midwives, 79.3 % (n = 261) reported that they had received nutrition information or education during their midwifery education and/or during practice. Table 5.2 presents details of the nutrition education received during midwifery education and/or after registration. It was mainly provided by midwives (67.4%, n = 176), followed by dietitians/nutritionists (56%, n = 147). Instruction by other health professionals and organisations and self-directed learning (SDL) also made a contribution (24.5%, n = 64).

The most frequent nutrition topics covered were nutrition during pregnancy, for example, the role of folate, iodine, or calcium; ; and the healthy range of weight gain required for pregnant women during different stages of pregnancy (78.9%, 77.0% and 75.1% respectively) (Table 5.2). Other nutrition topics included: managing nausea, constipation, or heartburn; food safety and preparation (e.g., listeria); breastfeeding; and gestational diabetes management. Topics reported to a lesser extent were: managing weight, and reviewing diet for nutrition requirements of pregnancy (44.1% and 42.5% respectively). The least covered topics were nutrition during pregnancy and different cultural groups, and nutrition and teenage pregnancy (20.7% and 20.7% respectively). General nutrition topics were also covered to a lesser extent, including: the role of vitamins and minerals in the body, general food safety, and prevention of chronic illnesses such as cancer and heart disease. In addition to the provided list of topics, a few midwives added other topics (Table 5.2).

One hundred thirty-three respondents (40.4%) provided details of their nutrition education during midwifery education. Of these, 42.9% (n = 57) provided approximate number of hours and/or sessions taught. The number of lectures was generally small, ranging from 1 to 6 lectures, while numbers of hours ranged from 10 minutes to 10 hours. Very few midwives (n

88

Table 5.1: Characteristics of the respondents Characteristics Number of responses (n*a) Percentage (%) Gender Female 325 98.8 Male 4 1.2 Age 21–30 years 28 8.5 31–40 years 55 16.7 41–50 years 95 28.9 Older than 50 years 151 45.9 Education Bachelor degree of Midwifery 74 22.5 Hospital-based training Midwifery 175 53.2 Initial midwifery postgraduate degree 80 24.3 Years of experience Less than 2 years 22 6.7 2–5 years 30 9.1 6–10 years 48 14.6 More than 10 years 229 69.6 Principal state or territory of work New South Wales (NSW) 96 29.2 Queensland (QLD) 78 23.7 South Australia (SA) 30 9.1 Tasmania (TAS) 8 2.4 Victoria (VIC) 58 17.6 Western Australia (WA) 40 12.2 Australian Capital Territory (ACT) 8 2.4 Northern Territory (NT) 11 3.3 Principal place of practice Public hospital 285 86.6 Private hospital 16 4.9 Independent midwifery practice 28 8.5 Level of maternity services Community 53 16.1 Rural hospital 53 16.1 Regional hospital 113 34.3 Tertiary referral 110 33.4 Area of midwifery practiceb Antenatal care 96 29.2 Birthing (labour) suite 54 16.4 Postnatal 89 27.1 Rotation through all the above areas 136 41.3 Group practice (case load or team midwifery) 67 20.4 Independent midwifery practice 28 8.5 a Total number = 329. b Multiple responses allowed. *The table is reused with permission from Elsevier.

89

= 6) reported receiving extensive coverage of nutrition (e.g., 30 hours or more), and when they did so, it had usually been provided as a separate unit that lasted for a semester or a year. The nutrition education was offered in a range of educational, clinical and community settings.

Thirty-four (10.3%) indicated that the nutrition education provided was limited, more focused on the basics or foods to avoid, and mostly integrated with other topics rather than being presented separately. According to one respondent, such education provided only a very small amount of information about foods that pregnant women should avoid. (Participant 278)

Details of their nutrition education during practice were provided by 149 respondents. Of these, 58 respondents reported the duration of education sessions provided after registration. Sessions ranged from 20 minutes or an hour for individual lectures/sessions to 120 hours for separate units or courses.

Self-directed learning (SDL) was reported by 62 midwives, sometimes as their main or only avenue to obtain nutrition education. Self-directed learning avenues included: attending conferences/workshops; undertaking nutrition courses; reading scientific journals, books and pamphlets; and communicating with other health professionals.

Some midwives reported receiving in-service nutrition education (n = 22), while others reported accessing such education at their own expense.

None offered. Have accessed 2 day study days at own cost. (Participant 282)

In response to the question on whether their practice would benefit from receiving more nutrition information or education, 94.2% (n = 310) of the midwives responded ‘yes’, 1.22% (n = 4) ‘no’ and 4.6% (n = 15) ‘have not thought about it’. Of the 329 midwives, 40.1% (n = 132) provided further details. Many of the midwives’ written responses were related to professional commitment to their role. Many of the responses (59.1%, n = 78) indicated that more nutrition education would help improve their knowledge or keep it up to date, increase their confidence, and help them provide evidence-based, consistent advice.

Would feel more confident and knowledgeable in offering appropriate info[information] and advice re [on] diet and nutrition. (Participant 153)

A smaller group of midwives (n = 16) included comments that reflected a broad perspective of the importance of nutrition support to the health of the mother, baby, and the whole family.

90

Diet is key to good health and if we teach the mother how to eat right then we impact the whole family. We also reduce the complications of pregnancy if we get good diet and weight management. (Participant 287)

Table 5.2: Nutrition information/education details Nutrition education details na % The providers of nutrition education b Midwives 176 67.4 Dietitians/nutritionists 147 56.3 Obstetricians or other doctors 36 13.8 Other c 64 24.5 I do not know 25 9.6 Nutrition topics covered in the education b Topics of nutrition during pregnancy Nutrition during pregnancy, for example, the role of folate, iodine or calcium 206 78.9 Alcohol and pregnancy 201 77.0 The healthy range of weight gain required for pregnant women during 196 75.1 different stages of pregnancy Nutrition-related issues such as managing nausea, constipation or heartburn 178 68.2 Food safety and preparation during pregnancy (e.g., listeria) 174 66.7 Nutrition for breastfeeding 173 66.3 Nutrition management of gestational diabetes 164 62.8 Managing weight during pregnancy 115 44.1 Reviewing diet for nutrition requirements of pregnancy 111 42.5 Nutrition during pregnancy and different cultural groups 54 20.7 Nutrition and teenage pregnancy 54 20.7 Topics of general nutrition General nutrient information, e.g., the role of vitamins and minerals in the 124 47.5 body General food safety 95 36.4 General nutrition , for example, prevention of chronic illnesses such as cancer 46 17.6 and heart diseases Other d 10 3.8 a n = 261 (only midwives who received nutrition information/education during midwifery education or after registration answered this section) b Multiple responses allowed c ‘Other’ included: self-directed learning (through internet, media, reading books, journals and attending conferences), complementary therapists (such as naturopaths and homeopaths), chiropractors, diabetes educators, midwives (colleagues, lecturers, and presenters in conferences or online) drug companies representatives, drug and alcohol staff and nurses, nutrition experts, kinesiologists, International Board Certified Lactation Consultant (IBCLC) course educators, governmental organisations, health promotion officers and interaction with pregnant women. d ‘Other’ included: nutrition for newborn and infants, nutrition during labour and after birth (especially for women from different cultural backgrounds such as Asian, Muslim and African women), nutrition for vegetarians and vegans, nutrition for fertility, nutrition for alleviating symptoms such as thrush, eczema and allergies, nutrition for preconception, the impact of maternal nutrition on child health, the effects of socio- economic factors on nutrition status, supplements and organic food.

91

Some midwives (n = 10) expressed a desire for greater nutrition knowledge to help them provide accurate information in regard to more specific pregnancy-related issues, such as the prevention and management of obesity and diabetes, as well as allergies, and nutritional challenges associated with the culturally diverse women presenting.

We are seeing more obese women and it is difficult to give them advice on weight management during pregnancy. (Participant 115)

Ten midwives specifically expressed their belief that it was part of their professional role to provide nutrition advice to pregnant women.

Midwives are often the first contact a mother has with a health professional during her pregnancy and should be given every opportunity to expand knowledge and give the best advice to mothers and their families. (Participant 208)

Structural constraints also prompted midwives desire to seek greater nutrition education (n = 4); For example, their role was considered particularly important due to limited availability of dietitians’ services.

Currently unable to refer women to[the] dietitian, [due to] (funding)… therefore midwives, especially those involved in continuity of care models are at the coal face to make changes given they have the right information and tools to do so. (Participant 107)

A few midwives (n = 4) believed they do not receive enough nutrition education despite their being the health professionals with the most contact with pregnant women.

Very little education or resources are directed towards midwives in this area and we are the health professionals who spend most time with the women. (Participant 311)

Some midwives (n = 10) were either opposed to receiving more information or had not thought about it or wanted more information but had reservations. Three thought that dietitians are better positioned to provide specialised advice and they should be seen by all pregnant women. Others (n = 4) thought that even if education was provided, it would need regular updates and might not be possible for every issue, specific enough, or conveyed to women due to time constraints. One midwife exhibited a lack of confidence in current dietary guidelines.

92

Yes I would like to do more study re [on] nutrition but I am not confident that our current dietary guidelines are leading our society to greater health and so I would not be keen to study “mainstream” dietary information. I believe though that good nutrition is the basis for good health and so is an essential aspect of pregnancy care. (Participant 232)

Some midwives (n =14) indicated a range of topics they would like to have covered in ongoing education, including: obesity, gestational diabetes, nutrients, diets for women from different cultural backgrounds or women living in remote areas, special diets, weight loss for post-partum women, and exercise. Three types of education were suggested by six midwives: hard copy information and references; guidelines in an easy access format; and regular updates such as in-service and professional development sessions.

The majority of the respondents (87.8%, n = 289) thought that Australian midwives would benefit from guidelines specifically tailored for them to provide pregnant women with nutrition advice, 3% (n = 10) disagreed, while 9.1% (n = 30) had not thought about it. When asked to explain their answers, 36.2% (n = 119) responded. Their explanations for why nutrition guidelines could be beneficial included that the guidelines would encourage midwives to provide more evidence-based, consistent advice and reduce conflicting information for both midwives and women (n = 52). It would also overcome the lack of clinical guidelines specific to Australia, unlike those for smoking and diabetes (n = 9). Given the importance of nutrition and midwives’ role in nutrition advice (n = 15), clinical guidelines would overcome midwives’ lack of nutrition knowledge, the current failure to uniformly provide adequate nutrition education in midwifery education and practice, and limited access to dietitians (n = 10).

Things work so much better when we eliminate some of the shades of grey....a consistent guideline would be terrific in many areas of maternity care, not just nutrition advice. (Participant 48)

A small number (n = 19) were in favour of guidelines tailored to their requirements but they had some reservations, while 18 midwives were not in favour of guidelines tailored to midwives’ needs or had not thought about it. Reservations about such guidelines included: the need for such guidelines to be evidence-based, user-friendly, women-centred, (and in one case, have a naturopathic holistic approach), involve midwives in their development, and be

93

regularly updated. One midwife commented that there are already available guidelines while another thought guidelines may restrict advice given.

Guidelines can be useful. However, yet another “tick box” would be annoying. Guidelines can potentially lead to prohibitive practice. (Participant 30)

Further reasons given against guidelines included that midwives need to collaborate with other health professionals (e.g., dietitians); and learning should be encouraged rather than merely relying on guidelines.

My concern would be a one size fits all doesn't work for everyone, what is out there tends to be very middle-class/income, Anglo-Saxon, older/motivated women centric. Teenagers will tell you they choose the healthy options at McDonald’s (and mean it!). (Participant 91)

5.6 Discussion This study explored Australian midwives’ own accounts of the nutrition education they had received. The majority reported receiving some nutrition education during midwifery education and/or after registration; however, this education lacked focus on contemporary nutrition issues and was generally described as limited. The provision of nutrition education to the midwives was mainly midwifery driven with further involvement of professionals with relevant expertise, such as dietitians and to a lesser extent by obstetricians or other doctors. Some midwives reported attempting to address their lack of formal nutrition education through self-directed learning. The majority indicated a need for increased nutrition education and guidelines tailored for them to provide nutrition advice.

Midwives generally commented that the coverage of nutrition during midwifery education was limited, integrated within other topics, and focused on the basics. The reported number of lectures and/or hours was small. Few midwives reported having a separate unit covering nutrition during pregnancy. Recent research (Arrish et al. 2016b) surveyed Australian accredited midwifery programmes and found that the number of hours of nutrition education in half of the programmes was only 5 to >10 hours, with only two programmes having a separate nutrition unit. There was also a lack of approaches to develop nutrition assessment skills or have practical nutrition training (Arrish et al. 2016b).

Limited nutrition education in midwifery programmes raises the need for those providing pre- registration education to review their coverage of nutrition. Midwives’ nutrition knowledge has been significantly linked to nutrition education received during their initi-

94 al education (Arrish et al. 2016a). However, it is unrealistic to assume that pre- registration nutrition content should suffice for all future practice, as professional knowledge is dynamic, evolving in line with the evidence base. Thus the role of pre- registration nutrition education in implementing necessary knowledge and skills that can be improved during practice cannot be ignored.

Several challenges have been identified in the literature that impact effective integration of nutrition education within health professionals’ education including: obtaining time within the curricula to integrate nutrition; focusing on teaching the role of nutrients in metabolic pathways rather than focusing on practical food-based knowledge; lack of emphasis on nutrition; lack of involving nutrition experts; and a lack of resources (Dimaria-Ghalili et al. 2013). A competency-based nutrition education addressing clinical and public health nutrition and inter-professional collaboration have been suggested as strategies to tackle these challenges (Kris-Etherton et al. 2015).

In response to the lack of subsequent formal opportunities for nutrition education during practice, many of the midwives reported that they undertook self-directed learning or independent learning. Such learning (Knowles 1975) assumes that adult learners are mature, independent, self-directed, responsible, and individual; and their learning is connected to their social roles and previous experiences, so they need approaches where they are partners rather than passive receivers (Murad and Varkey 2008). The overwhelming availability of new content (such as new areas of nutrition information) and competency-based education have increased the interest in SDL (Murad and Varkey 2008). Although SDL is considered as the most suitable model for health professionals to keep their knowledge up to date, there are mixed results about the effectiveness of SDL models compared to traditional learning models (Murad et al. 2010). It was found that it is more effective in improving knowledge than attitudes and skills (Murad et al. 2010). It is also more suitable to advanced learners (Murad and Varkey 2008). There are also no consistent means to determine the learner readiness to SDL and the nature of the content most appropriate to SDL (Murad and Varkey 2008).

The majority of the midwives in this study were mature in age and this might be the reason for referring to SDL as a way of obtaining nutrition education. However, the suitability of SDL in nutrition education remains unknown for younger midwives specifically and for midwives in general. Further research in this regard is needed. From our study self-directed learning seemed to involve some issues such as the outlay of personal funds (not all

95 midwives may be in a position to do so) and the variable quality of the nutrition education received. Midwives would benefit from being offered affordable and easily accessible nutrition education from trusted midwifery organisations and their workplaces. Access to information from dietitians as the experts in the field would also benefit midwives.

Other midwives were the main providers of nutrition education to the participants. However, it was identified that midwives may themselves receive limited education in nutrition. The provision of nutrition education by professionals with relevant expertise, such as dietitians, was mentioned by around 60% of the midwives. This is not unexpected, as dietitians were found to be rarely involved in teaching nutrition content within Australian midwifery programmes (Arrish et al. 2016b). Other research has suggested that collaboration between dietitians and midwifery academics in terms of nutrition education for midwives is feasible and could help improve midwives’ nutrition knowledge (Elias and Stewart 2005).

Variable nutrition coverage within midwifery education and/or after registration may result in variable quality of midwifery practice in this important area. Primarily it focussed on basic and theoretical topics. Complex topics and those incorporating practical or management skills (such as weight management and reviewing diet for nutrition requirements of pregnancy) were reported less frequently. Similar results have been reported previously (Elias and Green 2007, McNeill et al. 2012). According to the ICM Essential Competencies, midwives should have the knowledge/skills to assess women nutritionally (International Confederation of Midwives 2010). The ability of midwives to manage weight is essential given the high rates of overweight and obesity among childbearing women (Australian Bureau of Statistics 2013). Midwives in this study listed the increasing rates of obesity as a reason for the need for greater nutrition information and specific guidelines. A previous study has found that Australian midwives using evidence-based guidelines to manage obesity were more likely to report adequate education and greater confidence in counselling (Biro et al. 2013).

Of concern was the identification of the least covered nutrition topics, particularly nutrition for different cultural groups, and nutrition and teenage pregnancy. Pregnant women from different cultural backgrounds and pregnant teenagers are nutritionally vulnerable groups (Williamson 2006). The results of this study are consistent with previous international research that found that midwives lacked sufficient knowledge and skills to counsel pregnant women from different cultures (Wennberg et al. 2014). Midwives specifically pointed out that they would benefit from greater knowledge/clinical guidelines, and in-service education

96 of diets of women from culturally diverse backgrounds that would help them in these circumstances.

It was not possible to distinguish which phase, either during midwifery education or practice, the midwives were referring to in their answers to the questions regarding the providers of nutrition education and the topics covered. Fifty-seven per cent of the midwives were aged 41 and older; thus they may have received their midwifery education some time ago and 50% of the midwives reported that they had gained their education through the now abandoned hospital-based training rather than through university education. However, the pattern of topics reported as included within their received nutrition education was similar to topics reported to be covered in contemporary Australian midwifery programmes (Arrish et al. 2016b). This may imply little change in the pattern of nutrition topics covered within midwifery education. It may not reflect the changes in nutrition knowledge and advances in the understanding of the importance of nutrition during pregnancy, or the changes in midwifery practice, such as increasing numbers of women with obesity or diabetes, or the greater diversity of vulnerable women.

Midwives in this study believed in the importance of nutrition during pregnancy and their role in providing advice and therefore their need for more nutrition education and specific guidelines. The realisation by the midwives of the need to provide evidence- based, consistent advice is understandable. There is currently an overwhelming amount of nutrition information available in the media, particularly on the Internet, with many confusing messages that are not scientifically proven. Nutrition science continues to develop and new information is constantly emerging. This presents challenges for busy midwives. Formal updates from official organisations such as the ACM and their workplaces would ensure midwives are up-to-date with the latest evidence-based advances in nutrition. Prior research has also shown that midwives’ knowledge and confidence could be improved through compact training (Barrowclough and Ford 2001, Basu et al. 2014). Unfortunately, there is lack of the availability or provision of such intensive training in Australia (State of Queensland Queensland Health 2015).

Strategies for providing continuing education (e.g., online nutrition education) have some advantages, such as: reaching a wide audience with high-quality content; being an efficient, relatively low-cost method of delivery; providing convenient, self-paced study;

97 and being effective at building capacity. However, it requires funds to develop and sustain (Dimaria-Ghalili et al. 2013). Unless there are initiatives from the government and the professional bodies to provide such training, continuing nutrition education for health professionals will remain a challenge.

At the time of administrating the survey, the only available dietary guidelines were the Australian Dietary Guidelines (2003, revised in 2013) which were general guidelines and did not include advice specific to particular health professionals, such as midwives (who are not extensively trained in nutrition), on how to provide nutrition advice to pregnant women. In 2012 and 2014, Australia released its first National Antenatal Clinical Guidelines (Australian Health Ministers’ Advisory Council 2012, Australian Health Ministers’ Advisory Council 2014). A small number of the midwives expressed reservations regarding guidelines tailored to midwives’ needs and one midwife exhibited a lack of confidence in current dietary guidelines, which may reflect a tension between her personal views and her professional role. Future research could explore the views of midwives on the National Antenatal Clinical Guidelines; the support midwives should receive to incorporate the guidelines into midwifery practice; and the extent to which they are consistent with their expectations of their professional roles.

5.6.1 Limitations and strengths

While the response rate was low (6.9% of the members of ACM), it was similar to a previous study conducted with this cohort (Biro et al. 2013). Online surveys tend to have lower response rates compared to mailed surveys (Leece et al. 2004). The majority of the midwives were of mature age. Therefore, many were not able to provide the details of the nutrition education they received during their midwifery education several decades earlier. This may be due to the use of open-ended questions to obtain such data. The authors chose to use open- ended questions to give the participants the freedom of reporting their own experiences instead of providing limited certain answers. The use of both quantitative and qualitative data is a strength of this study. Quantitative data revealed that about 80% of the midwives received some nutrition education during midwifery education and/ or practice but the qualitative data highlighted the shortcomings of this education. The varying responses to the various questions eliciting midwives’ perceptions and needs did not permit exploration of associations of such responses with demographics or work characteristics of the participants.

98 5.6.2 Practical implications

National general recommendations can be made to include nutrition in a systematic way in midwifery programmes through the Australian Nursing and Midwifery Accreditation Council. Midwives need continuous support from official and trusted organisations, such as the ACM and their workplaces, to provide them with regular evidence-based nutrition updates, especially in terms of contemporary issues such as obesity. These recommendations can be applicable internationally through similar official midwifery organisations.

5.6.3 Future research

Younger midwives were under-represented in this study; future research should focus on investigating: newly graduated midwives’ perceptions of nutrition education received during midwifery education, and learning objectives regarding nutrition education within midwifery programmes to explore if skills to deal with challenging issues such as obesity are included in the curricula. Future studies also might explore the actual nutrition education being provided in midwifery programmes and how to make changes to curricula to facilitate the incorporation of nutrition education and the range of information that women seek from midwives, to ensure that the nutrition education within programmes is relevant.

5.7 Conclusion Australian midwives may not be adequately prepared to provide nutrition advice, a role that is increasingly important due to greater number of pregnant women with nutrition-related issues. Limited coverage of nutrition within midwifery or continuing education was reported, with personal initiatives undertaken to address nutrition information gaps. A more systematic approach aimed at ensuring all midwives have the basic nutrition knowledge and skills they require to provide nutrition advice to pregnant women, as outlined in the new Australian Antenatal Clinical Guidelines, is required.

5.8 Disclosure The Libyan Government was not involved in any part of the study.

5.9 Conflict of interest The authors declare that there are no conflicts of interest regarding the publication of this paper.

99 5.10 Acknowledgment The authors would like to thank: the members of the ACM who completed the survey, and Ms. Elaine Newby who provided editing assistance. This project was part of a doctoral scholarship for J. Arrish which was funded in part by the Libyan government. This research has also been conducted with the support of the Australian Government Research Training Programme Scholarship.

100

6 MIDWIVES’ ROLE IN PROVIDING NUTRITION ADVICE DURING PREGNANCY – MEETING THE CHALLENGES? A QUALITATIVE STUDY

6.1 Preface This chapter follows from the quantitative part (Chapters 4 and 5) of the practitioners’ arm (i.e. midwives) in achieving the overarching aim of this thesis, which is exploring the role of midwives in providing nutrition advice during pregnancy. The aim of the quantitative part was to reach a large number of the midwives and to generate objective data about their nutrition knowledge, attitudes, practices and education.

This qualitative study, with a sub-sample of the midwives who participated in the survey described in Chapters 4 and 5, aimed to gain more understanding of how midwives perceived their role in providing nutrition advice to pregnant women. As was explained in the conceptual framework (presented in Chapter 3), role perceptions, barriers and facilitators, and the model of care may influence midwives’ behaviour of providing prenatal nutrition advice. This study represents the qualitative investigation of these factors. The study aimed to answer these specific questions: how do midwives within different models of care provide nutrition advice and what are the barriers and challenges they face when advising women about their diets; and what might help midwives face these challenges, overcome the barriers, and be more effective in supporting women make informed decision about their diets. The findings are key for future research and policy aiming to expand the role of midwives in this area or make it more effective. The following chapter will present the content of the second arm included in the mixed methods design of this thesis, namely, the educators’ arm (i.e. the midwifery coordinators). The chapter will include both the quantitative and the qualitative parts.

Note: This chapter is a manuscript that was published in the journal of Nursing Research and Practice (see Appendix D) and is presented as it was published with minor modifications to conform to the University of Wollongong’ thesis guidelines.

Citation: Arrish, J., Yeatman, H. and Williamson M. (2017). "Midwives’ role in providing nutrition advice during pregnancy – Meeting the challenges? A qualitative study." Nursing Research and Practice. 17:7698510, p. 11. DOI:10.1155/2017/7698510.

Authors’ contribution: J. Arrish has main responsibility for study design, data acquisition, data analysis and interpretation, and writing, and submitting the manuscript. H. Yeatman and M. Williamson contributed to the conception of the study, analysis and interpretation of the results and the development of the manuscript. 101 6.2 Abstract This study explored the Australian midwives’ role in the provision of nutrition advice. Little is known about their perceptions of this role, the influence of the model of care, and the barriers and facilitators that may influence them providing quality nutrition advice to pregnant women. Semi-structured telephone interviews were undertaken with a sub-sample (n=16) of the members of the Australian College of Midwives who participated in an online survey about midwives’ nutrition knowledge, attitudes, and their confidence in providing nutrition advice during pregnancy. Thematic descriptive analysis was used to analyse the data. Midwives believed they have a vital role in providing nutrition advice to pregnant women in the context of health promotion. However, this was not reflected in the advice many of them provided, which in many accounts was passive and medically directed. The extent and efficacy of their role appears to be challenged by many structural barriers. Midwives suggested facilitators that may assist in overcoming these challenges. Midwives need assistance, support and guidance to provide holistic nutrition advice that assists women to achieve healthy pregnancies. A collaborative approach between midwifery bodies, nutrition and education experts, and maternity care services may provide an effective way forward.

Key words: Midwifery; role; perception; nutrition; education; advice, pregnancy.

102

6.3 Introduction The short and long term impacts of maternal diet on the health of the mother and the foetus are widely documented (Brantsæter et al. 2014, Davies et al. 2016). Pregnant women’s dietary behaviour is influenced by interpersonal, institutional ,and community factors (Fowles and Fowles 2008). Nutrition knowledge is one of those numerous factors that may affect women’s diet (Fowles and Fowles 2008) and pregnant women are perceived to be more receptive of nutrition information during pregnancy (Szwajcer et al. 2005). Nutrition education during pregnancy has been linked to positive maternal and infant outcomes (Thangaratinam et al. 2012), especially among overweight and obese women (Dodd et al. 2014). In spite of these positive links, the provision of nutrition advice by antenatal care providers is not common practice (de Jersey et al. 2013). In the literature, this lack of engagement with women in discussing their diet has been attributed to health care providers being challenged by factors such as limited time, resources and education (Lucas et al. 2014a).

Midwives are health care professionals perceived to be in a unique position to provide nutrition advice to pregnant women due to their usual contact with the women via antenatal appointments. Moreover, health promotion and education are considered among the most important activities that midwives perform with pregnant women as advocates for health and wellbeing rather than managers of diseases (Beldon and Crozier 2005). However, studies in the United Kingdom (UK) (Lee et al. 2012) and Sweden (Wennberg et al. 2014) reported that midwives struggle to provide dietary advice, especially in the context of health promotion and on challenging issues such as obesity, despite acknowledging it as part of their role (Lee et al. 2012).

A recent Australian quantitative study reported that the majority of the midwives believed that their role in providing nutrition advice is significant and the majority reported providing nutrition advice to pregnant women. However, some midwives provided written comments specifying barriers such as lack of time, resources and the model of care currently utilised as affecting their provision of such advice (Arrish et al. 2016a).

This study aimed to gain further understanding of midwives’ perceptions of their role, particularly: the effect of the model of care on the way they provide nutrition advice; the barriers that hinder their role, and the facilitators that may help them to provide better nutrition advice to pregnant women. These insights will contribute to pregnant women

103

receiving quality nutrition advice and support to help them make informed decisions about their diets.

6.4 Methods

6.4.1 Design

A qualitative descriptive approach was undertaken to gain an in-depth understanding of midwives’ perception of the importance of nutrition, how they learnt about nutrition, and how they educate women. The approach is useful when the aim of the research is to describe participants’ experiences and perceptions, as is the aim of this research (Neergaard et al. 2009). In the process of analysing the data and presenting them, there is rich and straightforward description of the participants’ experiences or related events (Neergaard et al. 2009). The analysis in this approach allows for reasonable interpretation but the researcher stays close to the data and participants’ own language (Neergaard et al. 2009). Semi- structured telephone interviews were employed. The interviews were flexible in style, structured around an interview guide and also included other probing questions that may arise during the interview. The questions were open-ended in nature, allowing respondents to give their answers in their own words and to express their ideas and opinions. The purpose of a semi-structured interview is to generate rich and candid data that lead to a deeper understanding of an issue (O’Leary 2004).

6.4.2 Sampling and participants

The participants were a convenience sub-sample of the members of the Australian College of Midwives (ACM) who participated in an online survey about midwives’ nutrition knowledge, attitudes, and their confidence in providing nutrition advice during pregnancy in 2012 (Arrish et al. 2016a).

6.4.3 Recruitment

In the participant information of the midwives’ online survey, an introduction about follow- up interviews was provided and a note was also included at the end of the survey. Midwives were directed to a separate page to indicate their consent to be contacted for the follow-up interview and to provide their contact details (i.e. names and email addresses). The intention was to gain the views of midwives across different ages and experiences. Therefore, the participants were asked to indicate their age category (i.e. younger than 35 or older than 35) and include their years of experience. The invitations for the interviews (including the

104

participation information sheet and the consent form) were formally sent in October 2012 to the midwives who had indicated their consent to being contacted for the follow-up. The participant information sheet explained the aim of the study, its significance, what the participants will do, the approximate time that will be taken for the interviews, and the participants’ right to refuse to participate or withdraw from the study with their data at any time without any effect on their relationship with the University of Wollongong or their place of employment. The participants were offered the opportunity to review their transcripts if they wanted. How the data will be disseminated was also explained. The participants were also given the details of the ethics committee of the university who they could approach with any concerns. They were given the opportunity to ask any questions at any stage. Reminders to non-respondents were sent in November 2012 and January 2013. Participants who returned their signed consent forms were sent a form to: indicate their preferred option for the interview (Skype or telephone), provide their phone number if they chose the telephone or their Skype account’s details if they chose Skype, and provide their preferred dates for the interview.

6.4.4 Data collection

The primary researcher (JA) conducted the semi-structured telephone interviews between October 2012 and March 2013. The interviews were audio-recorded. The length of the interviews averaged 21 minutes. The main questions that were used as a guide during the interviews were as follows:

(1) Can you please describe the model of care you follow/practise as a midwife?

(2) I would be interested to hear your views of how food selection and nutrition during pregnancy could influence pregnancy outcomes.

(3) What are the most important food issues that you usually discuss with pregnant women during their antenatal visits? What are the issues that should be discussed from your point of view?

(4) In what ways do you think your model of care affects the way you provide nutrition advice?

(5) Please describe for me the role you think midwives should have in regard to providing food-related or nutrition advice to women during pregnancy?

105

i. What preparation do you think midwives receive to provide such advice?

ii. What are the barriers that midwives encounter in relation to providing such advice?

iii. What guidelines or sources of information are available to midwives relating to providing nutrition information to pregnant women?

(6) What might assist midwives to provide better services for pregnant women in regard to food-related or nutrition advice?

(7) Would you like to add anything else?

Further questions or prompts derived from the interviews were used as relevant. The interview guide was developed by JA. The development of the guide was informed by the literature and the aim to deepen the understanding of the findings of the survey. The co- researchers, two experts (midwifery and public health), and a dietitian reviewed the interview guide to determine its relevance to achieve the aims of the study..

6.4.5 Data analysis

All interviews were transcribed verbatim by a professional transcriber. The interviews were then checked for accuracy by the primary researcher (JA). The Software QSR International’s NVivo11 was used to manage the data. Thematic descriptive analysis was used (Braun and Clarke 2006). The transcripts were read and reread by JA to ensure familiarity with the data and the audio recordings were referred to frequently to interpret the answers in their actual context. Open coding of the transcripts was undertaken inductively. Two researchers (JA and MW) undertook independent coding to ensure agreement of coding and establish validity. When disagreement existed, the coding was discussed between the researchers until consensus was reached. JA completed the analysis, organised the descriptive themes, and verified them with all co-researchers.

106

6.4.6 Ethical considerations

The University of Wollongong Health and Medical Human Research Ethics Committee approved the study (HE12/009). In the participation information of the online survey, the interested midwives were assured that their personal details would be secure if they decided to participate and their anonymity would be reserved. All participating midwives sent their signed consent forms either by email or through the post via the means of pre-paid envelopes. A verbal confirmation was also indicated at the beginning of the interviews.

6.5 Findings

6.5.1 Participants

Fifty-two midwives consented to be contacted for the interviews and provided their contact details. Nineteen midwives signed their consent forms and sent them back but three midwives did not send the forms of dates and other details despite multiple contacts. Hence 16 midwives (all of which were female) participated in the study. All, but one, midwives were older than 35 years of age. The participants’ years of experience ranged from 2 years to 37 years. Table 6.1 shows the models of care that the midwives specified they were employed in. The midwives worked in a variety of settings including public hospitals, private hospitals, private practice, hospital and community antenatal clinics, and birth centres. Some midwives had one role, while others had more than one role. For some midwives, antenatal care was their main area of work and expertise while others rotated through different areas (i.e., birthing suite and postnatal care). Some midwives worked individually while others worked in teams. Seven of the midwives specified that their models provided continuity of care, while eight midwives did not work in continuity of care models but rather provided fragmented care. One midwife had two roles providing both continuity of care and fragmented care.

107

Table 6.1: Midwives’ specified models of care

Midwife number Models of care as specified by the midwives Midwife 1 The team leader, midwifery-led model of care/continuity of care. Midwife 2 Lactation consultant/also has a private practice/does antenatal care but works mostly in postnatal care. Midwife 3 Caseload/continuity of care. Midwife 4 Community-based model/continuity of care. Midwife 5 Hospital/rotate through different areas and does antenatal clinic/fragmented care/had been doing antenatal care for a few months. Midwife 6 Private hospital/see women at booking only. Midwife 7 Midwifery-led care/continuity of care. Midwife 8 Hospital/midwifery educator/does antenatal clinic/fragmented care. Midwife 9 Private practice for an obstetrician/fragmented care. Midwife 10 Hospital/rotate through different areas/fragmented care/also a clinical midwife for midwifery model of care for Aboriginal and Torres Strait Islander women. Midwife 11 Public hospital/fragmented care/mainly antenatal care in an Aboriginal health clinic and a midwives’ clinic in the country/also has private practice. Midwife 12 Community-based/continuity of care. Midwife 13 Team midwifery/birth centre/continuity of care. Midwife 14 Hospital/educator/does antenatal classes/used to work in clinical area. Midwife 15 Multidisciplinary team of midwives with residents and consultants/rotate through the clinic/fragmented care. Midwife 16 Midwifery Group Practice (Caseload)/continuity of care.

6.5.2 Perceptions of midwives’ role in providing nutrition advice

The majority of the participants perceived the provision of nutrition advice to pregnant women as a vital part of the midwives’ role. They considered that midwives have a unique opportunity to do so as they are the health professionals who have the most contact with pregnant women. Some midwives indicated that this opportunity would be greater in a midwifery-led continuity of care model.

I think midwives are health promoters....Health educators….I think midwives have a unique opportunity to engage with women at that level and if you’re providing, if you’re a continuity of carer, so that means that a woman’s having care from a known midwife then basically throughout the pregnancy you can establish a relationship of trust and respect, and then you can work with the women more closely with regards to their specific lives.... support her to provide good nutrition for her family. (Midwife 1)

There was a general consensus that midwives are the ‘first port of call’ and not the experts, so they provide general or basic nutrition advice within the context of health promotion and primary health care. Providing nutrition advice for specific or complex issues is the role of the experts, ‘dietitians’.

108

I think midwives are the first port of call…. I think the midwives can provide the basic information and if there is a particular problem or if there’s a lady [who] has got a particular dietary problem that’s when you would refer to a specialist, a dietitian. (Midwife 2)

Despite believing in their role in providing nutrition advice, some midwives pointed out that the extent of this role either depends on the model of care or practice setting, or is largely restricted by many barriers such as time and model of care.

Well, in an ideal world pregnant women in Australia would have midwifery-led care ... from conception right through pregnancy til 6 weeks afterwards…. So it’d just be a gradual osmosis of information throughout the pregnancy on diet and, you know, alcohol and nicotine and it’d just be gradual. (Midwife 14)

6.5.3 Effect of model of care on the provision of nutrition advice

6.5.3.1 Continuity of care versus fragmented care Midwives in midwifery-led continuity of care models believed that the best advantage of their model of care was the ability to build a relationship with the women based on trust, respect and confidence. In this context, the woman would feel comfortable talking about her dietary behaviour with the midwife and the midwife would feel comfortable approaching the woman to provide woman-centred advice. They also thought that continuity of care models allowed more time for the provision of verbal, gradual and deeper nutrition information that could be absorbed by the woman.

….I’ve got a lot of time to spend with them.…I get the feeling that they trust me and that they would trust my advice….Because I see them regularly, I can give them just bite size amounts of information which can be absorbed quite well rather than great lumps of stuff. Also most of it’s a verbal education therefore there’s not all the written stuff so I’m not relying on their literacy skills. (Midwife 12, Community- based/continuity of care model)

One midwife thought of nutrition as a means to help improve birth outcomes for her women.

109

Well, it’s very important to me as a practitioner… that I’ve done everything that I can antenatally to get the best outcome at the birth because most of my clients are home birthers….So I want them to be really healthy, really well nourished, really strong, prepared for labour, so everything goes as smoothly as possible. (Midwife 7, Midwifery-led care/continuity of care)

Some midwives discussed customising their advice and messages according to their perceptions or assumptions of the women they took care of.

I think in that context of the birth centre generally women are well educated. It’s really just reinforcing what a lot of women know…. (Midwife 13, group practice/birth centre/continuity of care)

Midwives employed in public hospitals or the private sector in traditional fragmented models of care and not continuity of care midwifery models, on the other hand, felt affected by many factors in the way they provided nutrition advice. Most signalled that their model of care did not allow enough time, opportunities, or early involvement to build a relationship with the women and provide effective education.

...if you know that you’re going to see them a few more times, then you can actually build a relationship and then start to build up your rapport and their trust in you to the point where they’re going to be willing to accept what you have to tell them. (Midwife 5, hospital/rotating through all areas and does antenatal clinic/fragmented care)

One midwife working with an obstetrician in a private hospital mentioned being restricted by his practice and beliefs in the way she advised women about nutrition. She also thought that she would be more forthcoming in discussing nutrition if she was working in the public sector.

…[the obstetrician] was popular…I had to be mindful of what he felt and the way he worked and therefore I didn’t want to upset anybody commenting on their weight or giving them advice if it was unasked for….So if somebody asked me or made a comment about being overweight, what can I do about it, then I would offer it, but I didn’t volunteer it. (Midwife 9, private practice for an obstetrician/fragmented care)

110

A few participants presented their model of care as a holistic model looking at the women ‘as a whole’. They expressed the view that the health of the women is affected by many factors, and nutrition can affect the woman’s health and that of her baby and family in many ways during and beyond pregnancy. In comparisons to other health professionals such as doctors and dietitians, one midwife thought that midwives generally focused more on nutrition education compared to doctors, while another acknowledged that her technical knowledge is limited compared to a dietitian but this suited the low level of literacy of the women she worked with.

….I think, in some ways, the fact that I don’t have a lot of the really technical scientific knowledge around nutrition maybe doesn’t actually matter that much in the sense that for many of my clients their own…literacy skills can be quite limited and their language skills can be quite limited. So actually keeping things really, really succinct and simple is quite important in providing meaningful education…(Midwife 4, community-based/continuity of care model)

All midwives agreed on the importance of nutrition during pregnancy and were generally aware that it has impacts on the health of the mother and the baby. However, not all midwives could name specific pregnancy outcomes affected by nutrition behaviour and food selection of pregnant women.

Some midwives viewed nutrition as the ‘first medicine’, so they tended to favour food over supplements when discussing nutrition issues with pregnant women, especially as it was believed that women were commonly more receptive of nutrition messages while pregnant.

So in terms of just women in pregnancy I think our team’s attitude was that nutrition should be the first medicine….So then if you’re looking at say a woman who has low- ish iron stores at the beginning of pregnancy then we’re looking at foods to increase her iron source…we’re also looking at micronutrients in food as opposed to going to the chemist and buying a tablet. (Midwife 1)

Poor nutrition during pregnancy was believed to be linked to outcomes such as: preterm birth, large babies, post-partum haemorrhage, overweight, obesity, neural tube defects, anaemia, gestational diabetes, limited choice of model of care, miscarriage or stillbirth due to listeria, and for the baby to be prone to chronic diseases later in life. Good nutrition on the other hand

111

was linked to better health for the mother and the baby, managing pregnancy outcomes, and preventing complications such as gestational diabetes.

Nutrition was not routinely discussed, especially in a comprehensive manner. All midwives discussed nutrition issues on some level; however, on closer examination many midwives used generalised or passive approaches, where they considered the provision of written information sufficient, especially in terms of healthy eating advice for women they perceived or assumed to be healthy women.

So in terms of information about nutrition on their booking, we would give women information about nutrition on booking, a written pamphlet. It was generated from Better Health; Victoria has a Better Health channel which gave a good overview. (Midwife 1)

There was more focus on certain aspects of nutrition during pregnancy, especially those related to biomedical knowledge and blood tests when suspecting a deficiency or managing an issue. This approach was in contrast to midwives’ perception of their role in providing nutrition advice as health promoters and followers of a holistic approach.

…I suppose the main one was in the birth centre context that we tend to have more discussion over is anaemia. So the influence is the woman’s iron is staying down low, of course you’ve got the potential for either being affected if, you know, they have a normal blood loss or the risk of you know, postpartum haemorrhage, recovery, long term breastfeeding, you know, so we talk in those contexts if we find that someone’s iron is down low…The other dietary aspects, so within the anaemia realm you know, you’re looking at women who maybe are vegetarian so making sure women have a very well rounded base with a vegetarian and supplements, so all of those things. (Midwife 13)

Some midwives had an active and individualised approach to discussing nutrition with the women, where they provided verbal advice and did not merely depend on written information. These midwives reported they discussed the woman’s diet and provided advice accordingly.

While some midwives focused on certain nutrition aspects relevant to the women they provided care for (e.g., alcohol), others reported they abstained from discussing some aspects of nutrition (e.g., listeria and folic acid, or reducing consumption of caffeinated drinks and

112

junk food). This was based on their assumptions of women’s prior knowledge of the topic. Midwives made assumptions about a woman’s status and attitudes (i.e. perceiving the woman to be motivated, well, or educated). Also, as a result of late professional encounters with the women, midwives reported assuming they were already informed (either the women had sought information themselves or had received information earlier from other health professionals).

In terms of weight issues, not all midwives mentioned discussing weight with the women, and some among those who reported doing so, did not address it in-depth or directly. Among the reasons mentioned was avoidance of causing worry to the women and trying to minimise the guilt around weight gain.

…I guess I try and minimise the guilt factor in how much weight they put on because there’s such a wide range and as long as they’re healthy. (Midwife 2)

Some midwives indicated that if they had more time, knowledge and resources, they would like to focus more on promoting healthy eating in general and specific aspects related to pregnancy (e.g., obesity and diet for women from different cultural backgrounds). They indicated they believed that providing adequate support to women to improve their health was important as pregnancy is a great time to do so.

6.5.4 Preparation to provide nutrition advice

Half of the midwives believed that the coverage of nutrition during pregnancy within their midwifery education was non-existent or limited. If they recalled having received such pregnancy nutrition education, they remembered it as being mainly focused on basics and lacking variation. Some of those midwives indicated that they gained most of their knowledge through work experience and communicating with other health professionals such as dietitians, a process which was perceived to be more difficult than being taught in a formal manner.

Some midwives reported receiving nutrition education during their initial education, either in nursing or midwifery education. However, nutrition education was perceived as like any other area where learning is life-long and it needed continuing education.

…I mean I’ve been a midwife for a long time and I also did general nursing first. So…in my general nursing there was fairly good,...education on nutrition but it’s a

113

long time ago. And then it’s really just what I've read…and I think I’ve got knowledge gaps as well, so…I think all midwives should have ongoing education in nutrition because,…things change and we learn new information and that’s not necessarily,…spread to the people working in the work place. (Midwife 10)

Most of the midwives in this study were of mature age and some mentioned being trained through hospitals. Many acknowledged that they were not aware of the nutrition education provided in Australian midwifery courses offered at universities but hoped that there is inclusion of current nutrition-related issues and specific issues such as food intolerances and special diets. However, one midwife who was trained through hospitals had also done a Bachelor of Midwifery in the university system. She undertook a designated unit on nutrition but reported it had focused more on breastfeeding than on maternal nutrition.

There was a general view that Australian midwives do not receive adequate formal nutrition continuing education or support while practising, perceiving this as a reflection of nutrition being a neglected area. Midwives especially remarked that there was a lack of continuing education activities or opportunities for education about nutrition during pregnancy in the broad sense. Nutrition issues were reported to be threaded into other issues rather than presented separately at conferences or during in-service education. The focus of the limited education that is available was perceived to be in relation to particular groups or issues (such as obesity), reflecting issues with a high public focus.

…in recent years, with the obesity issue it’s come back into the focus a whole lot more now. I mean there was a big focus a few years ago with listeria…there was a big push on…providing a whole list of foods to be avoided and then that sort of…went off the radar a bit and then it’s come back in again…it’s very limited, extremely limited. (Midwife 8)

Midwives considered self-directed learning (SDL) an essential part of their job and it was their responsibility to update their nutrition knowledge and practice. However, it was commented upon that lack of mandatory education might have led to more reliance on self- directed learning. This was problematic as it was believed that midwives would need to be highly motivated, interested, or working mostly in antenatal care to seek continuing education in nutrition.

114

…as a midwife in Australia, I don’t know that a lot of time is given to nutrition in pregnancy… it’s behoven on the midwife to go get and find more information, to find resources to support information to give women. (Midwife 1)

One midwife highlighted that continuing nutrition education should be a shared responsibility between midwives and their employers.

I think it’s the responsibility of both the employer and the midwife herself to make sure that they’re up to date with the knowledge that they need for their practice and…to keep abreast of…research that’s coming out and changes in guidelines and those sorts of things. (Midwife 4)

When asked what guidelines or sources of information are available for midwives to provide nutrition advice, most midwives referred to written information they usually provided to pregnant women. Half the participants relied on guidelines and/or government resources (e.g., brochures, booklets, and websites) specific to the state or territory in which they worked. A few referred to national sources such as the National Health and Medical Research Council dietary guidelines and ACM or international guidelines or resources such as the National Institute for Health and Care Excellence guidelines.

Midwives lacked awareness of any guidelines or specific resources available especially for midwives to guide them in providing nutrition advice to pregnant women, with one midwife suggesting that academics should develop such guidelines or resources.

…as far as I know there’s not actually any guidelines to guide midwives along nutrition….Certainly not in the midwifery guidelines. There’s a vague mention of it in one of the elements in the midwifery practice guidelines but it’s vague and not specific about how to teach or how to educate or how to get your information or anything else….It’s just saying that you should give good nutritional advice. (Midwife 12)

The reliability, validity and layout of sources of information used seemed important to midwives, especially when using online and non-governmental resources. Midwives commented that availability of the resources does not guarantee that midwives or women would access them.

Other sources of nutrition information were also mentioned by the participants, such as talking with dietitians, journal articles, resources provided by hospitals (e.g., handouts,

115 databases) or provided to hospitals in commercial packages (e.g., Bounty bag), and midwives’ experiences.

Some midwives highlighted issues or problems with such guidelines and resources; for example, the written resources were often focused on food hazards more than health promotion and polices were slow to respond to change.

6.5.5 Barriers midwives encounter in the provision of nutrition advice

The majority of the midwives, especially those involved in fragmented models of care, defined time constraints as one of the major barriers affecting their activities when it came to providing nutrition advice. Midwives in continuity of care models also commented on time constraints. From their perspective, midwives saw the public health system as providing limited time to engage with pregnant women in regard to nutrition, with some comparing their current privileged situation with previous experience in fragmented care.

Midwives commented that discussing nutrition took place usually at the booking visit, where the length of the visit was disproportional to the amount of work the midwife had to do and the amount of information the midwife had to convey to the women.

Well, I think time, if you work in a busy public hospital, time’s the number one…they have to do so much. Like, for instance, in a booking interview…, at our hospital, when you see a woman for the first time it’s an hour and a half interview and in that hour and a half you have to do so much, you’ve got to do their mental, physical, social history, psycho-social history, domestic violence screen, so many different things, and to throw nutrition into there, it’s important but it’s easily missed because of…all the paperwork, the documentation you have to do….(Midwife 14)

One midwife highlighted that lack of time in public hospitals was not only an obstacle to provide the information to the women but also an obstacle for the midwife to update their knowledge, allocate resources, and access experts who can provide such resources. This in turn can lead to a passive approach when conveying nutrition information.

…in the public system everything is tightening up a lot. So time restricts you not only giving your patient care and having time for the education but it’s also time for updating your practice, finding out new information, finding the brochures, accessing the dietitians and the people within the health system, the Allied Health people that

116

could provide that information for you. So very much you tend to fob people off and sort of say, well you’ll need to go and find that from there or you’ll say well do an Internet search, you’ll probably find that information there. (Midwife 12)

Midwives pointed out that lack of relevant and reliable nutrition education resources (such as handouts and web sites to refer women to or for the midwives to resource accurate information or continuing education from) may hinder their role in the provision of effective nutrition advice to pregnant women. This was particularly highlighted by midwives working with women from diverse linguistic and cultural backgrounds.

…it’s not just because I work with Aboriginal women. I think it’s working with women from culturally and linguistically diverse backgrounds, is that the actual resources that we have are very…targeted at middle class Caucasian women that have reasonable literacy skills ….And that’s, having resources that aren’t sort of targeted at a broader range group I think is part of the challenge…That would be from sort of a systems point of view. (Midwife 4)

Lack of nutrition knowledge was signalled by some midwives as a challenge to providing meaningful nutrition advice, especially lack of knowledge of other cultures’ food choices.

…we get a lot of Asian women and African women in our community because…we have refugees that are relocated in our area. They actually struggle quite a lot. Well, we don’t understand their culture anyway….So their foods, because they are quite different to ours…I’m not sure how we would manage, cross that sort of cultural barrier. So certainly there’s that barrier. (Midwife 12)

On the other hand, one midwife indicated that midwives are challenged by other sources of nutrition information, their reliability, and whether the mother trusts the midwives or those resources.

… As a midwife you’re competing with other sources of information and you don’t know whether they’re valid or…you don’t know how reliable they are and you also don’t know where…the woman’s choosing to put her trust… who she’s going to...rely on. (Midwife 5)

Other constraints related to the health system identified by the midwives included the model of care (as previously described) and late encounter with pregnant women.

117

… I think the restrictions are the fact that we don’t see them ‘til later in the pregnancy...Not ‘til about 13 weeks…well diet’s important the whole way through but…that first trimester’s already gone….And you sort of wonder how they’ve been eating that whole time…by the end of the first trimester that baby’s fully formed and just needs to grow so it’s so important what they eat but we don’t get hold of them until after that. (Midwife 3)

Many midwives commented that provision of the nutrition advice would be variable as it would be subject to midwives’ attitudes, such as their interest in nutrition (or lack thereof), and their perception of its importance, and even their ability to be an appropriate role model.

The problem is…if people are going to be discussing nutrition with mums, there needs to be an intrinsic interest there…I’m really disappointed when I see midwives with higher BMIs [Body Mass Index] trying to give out dietary advice, so really that midwife can’t take it herself so how can she be passing it on? (Midwife 11)

Approximately, one in three of the midwives pointed out women’s knowledge and attitudes as barriers to the provision of effective nutrition advice. ‘Lack of knowledge’ referred to foundational knowledge provided by subjects taught in secondary education and lack of food- related skills (i.e. how to make healthy choices, shop, budget, and prepare a meal). Attitudes included: lack of motivation to change dietary behaviour, lack of emphasis on diet compared to other issues (e.g., birth), body image (positive or negative), non-compliance (e.g., with gestational diabetes diet), guilty feelings; or fear of harming the baby.

Social determinants of health for the women, such as socio-economic status, environment (i.e. access to healthy and affordable food, and access to allied health care services in remote areas), language and literacy, and culture were also barriers mentioned by the midwives as obstacles to the provision of effective nutrition advice to pregnant women.

The other thing is I think as midwives we are very conscious that sometimes the women that we’re dealing with come from difficult circumstances so, you know, buying fresh fruit and vegetables might be difficult or cooking in your facility might be difficult, so you tend to opt for the easiest option and that often isn’t the best in terms of nutrition….That’s where… the social determinants of health affect a midwife’s ability to engage with a woman in regards to her nutrition…. (Midwife 1)

118

It was identified by a midwife that it is quite challenging to explain the concept of risk to women with lower education status as it may affect their reaction to the advice provided.

…we do talk about the concept of risk …. But many women have no antenatal care, do drink throughout their pregnancy, do smoke, baby’s not breastfed, baby’s put straight onto the bottle and that baby will still chart nicely along a growth chart, will still do OK at school, will still be born and look normal and be of a good weight and so that’s a really difficult, I think that’s a challenge ...Because the concept of risk is so abstract…. I think the expectations we have of clients to really understand that is, at times might be a little bit unrealistic….(Midwife 4)

Midwives also referred to women’s family and work commitments or incorrect advice from relatives as hurdles affecting their provision of nutrition advice.

The other challenge we have is the grandmothers...And they’re going… I ate whatever I felt like and you were fine so what’s the problem?... (Midwife 2)

6.5.6 Facilitators that would help midwives provide better nutrition advice

Midwives repeatedly commented that continuing education about nutrition issues or regular updates on the latest evidence-based nutrition information would be helpful for them to provide quality nutrition advice. However, they also stressed that continuing education or updates need to be provided by reliable sources such as the ACM and health services, as that would spare their time in navigating the abundant sources of information available. Online learning basic modules or courses and in-service education were frequently mentioned.

A common strategy suggested by the midwives was collaboration with allied health professionals, especially dietitians as they were perceived as the ‘experts’ who had the training and the knowledge. Collaboration with the dietitians and other alternative or allied health professionals (e.g., naturopaths and physiotherapists) took many forms. For example, some midwives suggested that dietitians should be involved in developing useful resources such as handouts, DVDs, and websites that the midwives can then use to enhance their practice or reinforce the messages they provided to pregnant women.

Other participants proposed that dietitians educate the midwives and the midwives can then pass this education to pregnant women. It was suggested that dietitians need to be involved in maternity care by participating not only in antenatal classes (as it was indicated this might be

119 late or may not capture all women) but also in antenatal appointments. One midwife even suggested the need for a permanent position for a dietitian in antenatal clinics, as regular hospital dietitians would not see pregnant women unless they had complex issues. This suggestion was based on her experience of having a temporary dietitian in her work place and how that was beneficial not only for pregnant women (who may need quick personal chats) but also for midwives who used talking with the dietitian as a source for up-to-date information. Having back-up dietitians in the community for pregnant women in the private sector was also recommended. However, it was realised that involving dietitians is a system issue that might involve time and cost.

….there should be the ability for midwives to be in collaboration with dietitians or nutritionists…I know that’s time consuming and I know that it’s often hard to negotiate that and… [it] costs money, however, I think that would be the best way to do it. (Midwife 12)

Another strategy to help in preparing midwifery students’ to provide better nutrition advice suggested by the participants was incorporating nutrition into midwifery education. Midwives also suggested specific attributes for this incorporation, including: as an in-depth compulsory designated unit in all midwifery programmes; in a broad way involving varied health professionals such as dietitians and naturopaths; and in a practical manner that meets the needs of practice in the real world.

Midwives also recommended other strategies related to the provision of nutrition advice in the antenatal care context in general. This included: better funding; standardisation of information; availability of resources that meet the needs of young women, such as special applications and web sites to enable early dissemination of nutrition information; and taking on a preventive approach rather than a management one. Other facilitating strategies included: the availability of literacy appropriate resources; increase the awareness of guidelines; and doing more research to improve nutrition education provided to pregnant women. A few midwives proposed that more time needed to be allocated to antenatal visits, so midwives could provide meaningful nutrition education.

Well, more time… at the end of the day if the midwives don’t have time to talk to women about nutrition, I guess there’s no point them resourcing the information…(Midwife 7)

120

6.6 Discussion This qualitative study explored Australian midwives’ perceptions of their role in providing nutrition advice, the effect of their model of care on this role, and what facilitated or hindered it. Midwives believed that they have a vital role in providing nutrition advice to pregnant women generally in the context of health promotion; however, this was not reflected in the advice many of them provided. The advice seemed in many accounts passive and more medically directed. Despite midwives’ beliefs in their role in this area, the extent and efficacy of this role appeared to be challenged by many barriers. Midwives suggested some facilitators that may help overcome these challenges.

The perception of midwives in this study was that providing nutrition advice to pregnant women was a vital part of their role. This is consistent with previous international literature and the quantitative results of the cohort from which this sample was recruited (Elias and Green 2007, Arrish et al. 2016a), especially in regard to providing holistic nutrition advice in the context of health promotion (Lee et al. 2012). Our findings also support the argument of Cheyne and Moreno-Black (2010) that midwives view food and nutrition as an integral part of the holistic care that underpins their midwifery model of care and as a means to maintain health and wellbeing. Similarly midwives in this study referred to viewing and using food as the ‘first medicine’ and as part of the holistic care they provided to pregnant women.

Despite midwives’ belief in their role in providing general nutrition advice in the context of health promotion, this was not reflected in the generalised or passive approach many midwives in this study utilised in the way they conveyed nutrition information to pregnant women. They expressed a tendency to rely on written information as a means for providing advice, particularly for women perceived and assumed to be healthy. These findings reflect the finding of Bondarianzadeh et al (2011) who found that Australian midwives have an over- reliance on written information and adopt mostly a passive approach when advising pregnant women about listeria.

Midwives’ advice in this study was on many accounts medically directed or provided when suspecting a deficiency or managing an issue. These results further confirm the quantitative findings of this cohort (Arrish et al. 2016a) and concurs with international research that has reported pregnant women received nutrition advice from midwives only when there were health issues or concerns (Wennberg et al. 2013). Some midwives in this study refrained from or adopted a passive approach in discussing certain topics with pregnant women when they

121 perceived them to be motivated and educated. While such an approach may be considered to have merit, it is not based on evidence. Bookari et al (2017) found that a sample of mostly highly-educated and motivated Australian pregnant women had poor nutrition knowledge and dietary behaviour and suggested health care providers should not base their provision of nutrition advice to those women on such assumptions.

The midwives’ accounts of the barriers and the challenges that restrict the midwife’s role in providing effective nutrition advice could be considered to be related to the health system or otherwise out of their control, citing issues such as: lack of time, lack of resources, limited basic and continuing nutrition education, and the effect of their model of care. These results are in line with earlier literature where insufficient time, resources and education were considered the main obstacles that impeded health care providers from educating pregnant women about nutrition (Lucas et al. 2014a).

The midwifery philosophy is centred on building a relationship with the women and supporting and empowering them to make informed decisions that will improve their health and ultimately the health of the society (Australian College of Midwives 2004). This relationship forms the basis for establishing rapport, trust, respect and confidence with the women which were the pillars of effective nutrition communication according to most midwives in this study. This was especially highlighted by the remarks of most midwives providing continuity of care. Lack of time to establish a relationship was frequently referred to as a barrier by the midwives (mostly in fragmented care) to their engaging with pregnant women in discussing nutrition issues, especially sensitive topics such as weight gain and obesity, which is consistent with previous studies (Davis et al. 2012). Motivational interviewing has been suggested as an effective strategy that can be used by midwives when approaching women with regard to sensitive issues such as obesity or to overcome barriers related to the women, such as their attitudes, for example (Raymond and Clements 2013). Several participants also suggested nutrition or health promotion approaches may be effective but there was little indication that they were informed about what such approaches may involve or whether they had the necessary skill set for such an approach.

Midwives suggested a number of facilitators to overcome the barriers that challenged their role in providing nutrition advice. Midwives requested continuing education in general nutrition. This may reflect their perceptions of the advice they needed to provide as ‘general’. They requested more education from reliable sources to feel supported and to reduce the over

122 reliance on SDL that was perceived to be dependent on time availability and midwives’ interest. They also requested collaboration with health professionals they considered the ‘experts’. While such continuing education may be helpful in relation to the nutrition content, midwives did not identify the need for in-service education in relation to the skills necessary to promote nutrition to pregnant women or support their attempts to change their diets.

Midwives in this study commented that they mainly relied on state-specific guidelines to guide their practice in providing nutrition advice but highlighted an absence of midwifery guidelines. National clinical guidelines have been developed in Australia since this study was undertaken (Australian Health Ministers’ Advisory Council 2012, Australian Health Ministers’ Advisory Council 2014). These guidelines specify that antenatal health care providers, including midwives, need to discuss nutrition at every antenatal opportunity by highlighting its importance, assessing maternal diets and providing advice in a holistic approach considering social determinants of health and referral to dietitians where appropriate. However, a recent Australian study examining women’s perceptions of antenatal care provided to them against those guidelines found weight gain and diet to be the areas raised the least (Waller et al. 2016). Midwives would need support on many levels if they are to discuss nutrition in an individualised and holistic approach, as specified by the current clinical guidelines. Intervention studies are needed to ascertain the best strategies to help midwives and other health care providers incorporate nutrition advice effectively into their practice and overcome common barriers.

6.6.1 Limitations and strengths

The nature of qualitative research limits its generalisability; however, this qualitative study enabled more understanding of midwives’ perceptions of their role in advising women about nutrition and the challenges that restricted this role. Even though only 16 midwives participated, they were from both public and private sectors and were engaged in various models of care. Saturation of data was reached at 16 interviews as no new ideas emerged. The majority of the participants were of mature age with less representation from younger midwives, reflecting the age profile of the midwifery workforce in 2012 (Australian Institute of Health and Welfare 2013).

123

6.6.2 Future research

Future research needs to involve interviewing younger or newly graduated midwives to explore their perceptions of their role in providing nutrition advice during pregnancy and their views of their educational preparations to provide such advice to cite any differences in this regard from the views of mature midwives interviewed in this study.

6.7 Conclusion Although midwives in this study perceived providing nutrition advice to pregnant women as an integral part of their practice as midwives, this role was felt to be constrained by many challenges and factors mostly out of the midwives’ control. Midwives need structured assistance, support, and guidance to provide holistic nutrition advice that assists women to achieve healthy pregnancies. Changes in the policy of health care services were suggested such as: allowing more time for antenatal visits; encouraging continuity of care for all women; creating permanent positions for dietitians in antenatal clinics; and developing free online nutrition models and training packages for practising midwives by the professional organisations. A collaborative approach between midwifery bodies, nutrition and education experts and maternity care services should be considered to implement such changes. While this study was confined to Australia, the findings and recommendations have relevance to other countries that support midwifery services.

6.8 Conflicts of interest The authors declare that there are no conflicts of interest regarding the publication of this paper.

6.9 Acknowledgment JA was a recipient of a doctoral scholarship from the Libyan government which partly supported this research. However, the Libyan government did not interfere with any part of the research. This research has also been conducted with the support of the Australian Government Research Training Programme Scholarship. The authors express their appreciation for all participating midwives for their valuable contribution to this project. The authors would also like to thank Ms. Cheryl Jecht for her assistance in transcribing the interviews and Ms. Elaine Newby for her assistance in editing the manuscript of this paper.

124

7 NUTRITION EDUCATION IN AUSTRALIAN MIDWIFERY PROGRAMMES: A MIXED-METHODS STUDY

7.1 Preface In the preceding chapters (4, 5 and 6), the first arm (the practitioners’ arm i.e. the midwives) in the mixed-methods design of this thesis investigated practising midwives nutrition knowledge, attitudes, and confidence (Chapter 4); received nutrition education (Chapter 5), and their perceptions of their role in providing nutrition advice (Chapter 6). Chapter 7 represents the second arm of this thesis, the education providers’ arm (i.e. the midwifery coordinators). It answers the fifth question of the research about what food and nutrition content and skills are being taught in midwifery programmes in Australia and whether this prepares midwives to provide effective nutrition education to pregnant women. This was undertaken through a mixed-methods study including both surveys and interviews conducted with the course coordinators of the Australian midwifery programmes. The study identified how nutrition is included in midwifery curricula, discussed the gaps, and suggested policy change and areas for further research. The next chapter outlines the overall discussion of the thesis, its recommendations, and conclusion.

Note: This chapter been written and published during the course of this degree in the Journal of Biomedical Education (see Appendix E) and is presented as it was published with minor modifications to conform to the University of Wollongong’ thesis guidelines.

Citation: Arrish, J., Yeatman, H. and Williamson M. (2016). "Nutrition education in Australian midwifery programmes: A mixed-methods study." Journal of Biomedical Education. 16:9680430, p. 12. DOI:10.1155/2016/9680430.

The findings have been also presented as a poster presentation in the 31st International Confederation of Midwives – Triennial Congress in Toronto, Canada, 2017 (see Appendix H).

Arrish, J., Yeatman, H. and Williamson M. (2017). "Making a difference through professionalism: The need for evidence-based nutrition in midwifery education." 31st International Confederation of Midwives – Triennial Congress. Toronto, Canada, 18–22 June 2017. Authors’ contribution: J. Arrish was mainly responsible for study design, data acquisition, data analysis and interpretation, and writing and submitting the manuscript. H. Yeatman and M. Williamson contributed to the conception of the study, analysis, and interpretation of the data and the development of the manuscript.

125 7.2 Abstract Little research has explored how nutrition content in midwifery education prepares midwives to provide prenatal nutrition advice. This study examined the nature and extent of nutrition education provided in Australian midwifery programmes. A mixed-methods approach was used, incorporating an online survey and telephone interviews. The survey analysis included 23 course coordinators representing 24 of 50 accredited midwifery programmes in 2012. Overall, the coordinators considered nutrition in midwifery curricula and the midwife’s role as important. All programmes included nutrition content; however, eleven had only 5 to <10 hours allocated to nutrition, while two had a designated unit. Various topics were covered. Dietitians/other nutrition experts were rarely involved in teaching or reviewing the nutrition content. Interviews with seven coordinators revealed that nutrition education tended to be problem-oriented and at times based on various assumptions. Nutrition content was not informed by professional or theoretical models. The development of nutrition assessment skills or practical training for midwifery students in providing nutrition advice was lacking. As nutrition is essential for maternal and foetal health, nutrition education in midwifery programmes needs to be reviewed, and minimum requirements should be included to improve midwives’ effectiveness in this area. This may require collaboration between nutrition experts and midwifery bodies.

Key words: Nutrition education; pregnancy; curriculum; midwifery programmes; mixed methods; Australia.

126 7.3 Introduction The importance of nutrition during pregnancy for mother and offspring is supported by a growing body of evidence (Hillesund et al. 2014, Davies et al. 2016). Pregnant women often display nutrition information seeking behaviour (Szwajcer et al. 2008). Information and advice about healthy eating during pregnancy/breastfeeding and about weight management are some of the topics specifically requested by pregnant women (Porteous et al. 2014). Health professionals rate the provision of nutrition advice during pregnancy as important/very important (Hughes et al. 2011). However, the proportion of those professionals providing advice across different nutrition topics is low (16–32%) (Hughes et al. 2011) and a majority of pregnant women do not receive appropriate nutrition advice from their health professionals (de Jersey et al. 2013).

Australian pregnant women have poor nutrition knowledge and behaviour despite being highly motivated and confident in their ability to adopt a healthy diet (Bookari et al. 2017). The midwife is considered a trusted source of information by pregnant women (Garnweidner et al. 2013). Australian midwives believe nutrition during pregnancy is important and they have a role in providing nutrition advice to pregnant women (Arrish et al. 2016a). However, their nutrition knowledge has been found to be lacking and only half report receiving nutrition education within their midwifery education or during practice (Arrish et al. 2016a). Educational gaps on particular aspects related to maternal nutrition, obesity, and weight management were indicated in international and Australian research (Touger-Decker et al. 2001, Elias and Green 2007, McNeill et al. 2012, Wilkinson and Stapleton 2012, Willcox et al. 2012). Attempts by two international universities to integrate nutrition within their curricula were briefly reported (Kolasa et al. 1997, Elias and Stewart 2005). There is a paucity of research about nutrition education provided in midwifery programmes.

In Australia, midwifery education is offered through both undergraduate and postgraduate programmes. Midwifery education is overseen by the Australian Nursing and Midwifery Council (ANMC). The name of the Council has changed to the Australian Nursing and Midwifery Accreditation Council (ANMAC), reflecting its role as the independent accrediting authority which sets the standards of accreditation for midwifery programmes (with the latest version released in October 2014) (Australian Nursing and Midwifery Council 2009, Australian Nursing and Midwifery Accreditation Council 2014). The Nursing and Midwifery Board of Australia (NMBA), the regulatory body of the nursing and midwifery

127

professions in Australia, approves the accredited programmes (Australian Nursing and Midwifery Accreditation Council 2014).

Successfully completing a midwifery programme accredited under the ANMAC Midwife Accreditation Standards enables graduates to apply for registration as a midwife in Australia (Australian Nursing and Midwifery Accreditation Council 2014). The ANMAC published the first National Competency Standards for the Midwife in 2006 following two years of research/development and validation, and they undergo regular review and revision (Australian Nursing and Midwifery Council 2006, Australian Nursing and Midwifery Accreditation Council 2014). These competency standards include the core competencies used by registration authorities, education providers and employers to assess if a midwife is competent for registration and practice (Australian Nursing and Midwifery Accreditation Council 2014).

The previous Accreditation Standards (Australian Nursing and Midwifery Council 2009) did not have any mention of nutrition (Arrish et al. 2014). The current ANMAC Midwife Accreditation Standards (Australian Nursing and Midwifery Accreditation Council 2014) have undergone minimal change in this regard. They emphasise that the curricula should be underpinned by ‘primary health care principles’ which include ‘promotion of food supply and proper nutrition’ (Australian Nursing and Midwifery Accreditation Council 2014). However, they do not stipulate any specific nutrition education requirements to be included in the curricula. The National Competency Standards for the Midwife specify public health issues that need to be addressed by the midwife, such as ‘promotion of breastfeeding’, ‘smoking cessation’, ‘domestic violence’, and ‘drugs or alcohol use’(Australian Nursing and Midwifery Council 2006). There is no mention of nutrition or the promotion of healthy eating. According to the International Confederation of Midwives (ICM) Essential Competencies for Basic Midwifery Practice (International Confederation of Midwives 2010 pp. 8 and 9) (revised 2013), midwives should have ‘the knowledge and/or understanding of nutritional requirements of the pregnant woman and foetus’ and ‘the skill and/or ability to assess maternal nutrition and its relationship to foetal growth; give appropriate advice on nutritional requirements of pregnancy and how to achieve them’. It would be expected that midwives require adequate education to provide such advice.

This study examined the nature and extent of nutrition education provided in Australian midwifery programmes.

128

7.4 Methodology

7.4.1 Study design

The study used a mixed-methods approach and consisted of two components: an online survey and semi-structured interviews. A convergent parallel design was utilised for the overall study. In this design, quantitative and qualitative data are collected and analysed independently within the same time frame of the research process (ideally given the same priority) and the results of both data are merged in the overall interpretation (Creswell and Clark 2011). The main purpose of this design is to obtain a comprehensive understanding of the topic under study and to validate or corroborate the results from one method with the results of the other (Creswell and Clark 2011).

7.4.2 Stage 1: The survey

7.4.2.1 The purpose The purpose of the survey was to investigate the extent and nature of nutrition education provided in Australian midwifery undergraduate and postgraduate programmes, and the views of midwifery coordinators on the midwife’s role in nutrition education and the importance of nutrition in midwifery curricula.

7.4.2.2 Respondents and survey dissemination The list (as at 1 May 2012) of all Australian accredited midwifery programmes leading to professional registration as approved by the NMBA was obtained from their website. The list included: 50 programmes comprising 23 undergraduate and 27 postgraduate degrees from 29 universities; the name of the approved institution/provider; the qualification provided (type of the programme e.g., undergraduate or postgraduate); the state or territory in which the programme was provided, and the period of accreditation.

Course coordinators were deemed the appropriate point of contact, as the ANMC accreditations standards (Australian Nursing and Midwifery Council 2009) did not have specific requirements for nutrition education within curricula, and the coordinator would have an overview of their programme content. The contact details of course coordinators for the identified programmes were obtained through searching of institutional websites and telephone enquiry. The coordinators were contacted via email and invited to participate in the study and complete the online survey. The invitation email had brief information about the

129

study, its aims, and the researchers’ contact details. It also had a hyperlink to the online survey. Three reminders were sent to non-respondents at one month, three months, and four months from the issue of the invitation. Survey responses were collected from June to December 2012.

7.4.2.3 Survey development and structure Only one survey investigating nutrition education of midwifery programmes was identified when the current study commenced (Touger-Decker et al. 2001) but it had a slightly different aim and was based on the United States of America’s specific nutrition competencies. Therefore, it was deemed not relevant to Australia for the purpose of this study.

A short survey consisting of 10 items was developed. Coordinators were asked to: indicate the degree/s they were coordinating; nominate the total number of hours allocated to nutrition in the curricula; nominate from a list of nutrition topics those covered in their curricula (formulated from prior literature and government websites) (Williamson 2006, Wilkinson and Tolcher 2010, Arrish et al. 2014, Better Health Channel 2014); indicate the professional qualifications of content providers; report the frequency of content review; indicate the involvement of experts in the review process and the qualifications of reviewers; and express their own views on the midwife’s role in nutrition education during pregnancy, including the significance of this role and the importance of nutrition education in midwifery curricula and for the clinical practice of midwives. Respondents were asked to rank their agreement with survey items using five-point scales (e.g., ‘very important’, ‘moderately important’, ‘important’, ‘slightly important’, and ‘not at all important’). Space was provided for respondents to supply any additional options or comments.

Two experts (in public health nutrition and midwifery) and a dietitian reviewed the survey for content, readability and relevance. As a pilot, the survey was then sent to five researchers and two course coordinators, one of whom was a coordinator of a midwifery programme. Minor modifications were undertaken based on their feedback. Survey Monkey Software (SurveyMonkey Inc. Palo Alto, California, USA, www.surveymonkey.com) was used to make the amended survey available online.

7.4.2.4 Data analysis The Statistical Package for the Social Sciences Software (SPSS) version 22 (Armonk, NY: IBM Corp.) was used for the analysis. Responses were reported by frequency and percentage. 130 Fisher’s exact test was used to examine the association between nutrition topics covered and programme type (i.e. undergraduate or postgraduate), and it was also used to examine the association between nutrition topics covered and seeking experts’ advice in reviewing the programme’s nutrition content. The association between hours allocated to nutrition and programme type was also examined. The answer of one coordinator who coordinated both undergraduate and postgraduate programmes at their institution was excluded in the comparison of nutrition topics between undergraduate and postgraduate midwifery programmes as their answer to that question related to both programmes and not one or the other. Statistical significance was set at alpha level of 0.05.

Responses on hours allocated to nutrition were categorised into four categories (<5 hours, 5 to <10 hours, 10 to <15 hours, and 15 hours or more). The four categories were combined into two categories (<10 hours or 10 hours and more) for the purpose of statistical analysis due to small numbers in some categories. Responses to open-ended survey questions were categorised and described.

7.4.3 Stage 2: The interview

7.4.3.1 The purpose The purpose of the interviews was to explore the coordinators’ perspectives on how nutrition is incorporated within their programmes and deepen the understanding of the findings of the quantitative study.

7.4.3.2 Data collection Qualitative description was the approach chosen for this study (Neergaard et al. 2009). Semi- structured telephone interviews were used to collect the data. In the email invitation to participate in the survey, a note about further contact at a later time for an interview and its purpose was included, and the coordinators were asked to email the researcher if they were interested to participate in the interviews. Those who did were contacted at that time and interviewed. Further invitations to participate in the interviews were emailed to the other coordinators in January 2013 and a reminder to non-respondents was sent in February 2013.

The semi-structured interviews were conducted and audio-recorded via the telephone by the lead author (JA) between November 2012 and March 2013. They lasted between 11 and 26 minutes with an average time of 15 minutes. An interview guide was used, as shown in the following: 131 (1) Can you please outline how food and nutrition issues are presented within the midwifery curriculum at your institution?

(a) What importance, if any, is placed on teaching about nutrition during pregnancy compared to other topics in your programme?

(b) Who is responsible for the nutrition components in your programme? Can you please outline any particular qualifications in nutrition held by these academics/guests?

(2) Can you please outline the development and review activities linked with the nutrition curriculum within your programme?

(3) Please outline how nutrition curriculum within your programme is informed by particular pedagogical or professional theoretical models.

(4) Are there any particular aspects of the curriculum that assist to prepare your graduates to provide evidence-based nutrition information?

(a) Any national standards that you follow?

(b) Development of nutrition assessment skills?

(c) Practical training in nutrition?

(5) How well do you think graduate midwives from your programme are prepared to provide evidence-based nutrition information for pregnant women?

(a) Are there any particular barriers that may impede them in this role? What facilitates their practice in this role?

(6) Do you have any other points that you would like to raise?

The questions were reviewed by the co-authors, two experts (midwifery and public health), and a dietitian. One interview was conducted with a midwifery course coordinator as a pilot.

7.4.3.3 Data analysis The interviews were transcribed verbatim by a professional transcriber and checked for accuracy by JA. Data analysis was facilitated by using QSR International’s NVivo11 Software. The interviews were analysed thematically in a descriptive manner. The lead author

132

read and reread the transcripts to become immersed in the data. All the authors coded one transcript independently and another one as a group and discussed the coding. The lead author then coded the rest of the transcripts and discussed the coding of all transcripts with one or both of the co-authors until consensus was reached. The lead author organised the descriptive themes, finalised the analysis, and confirmed the final results with the co-authors.

7.4.4 Ethical considerations

Ethical approval was received from the University of Wollongong Health and Medical Human Research Ethics Committee (HE12/038). The coordinators indicated their consent in the survey by completing it and provided consent for the interviews either orally or in a written format.

7.5 Results

7.5.1 Stage 1

Forty-four identified coordinators from 50 programmes (some coordinators coordinated more than one programme) were sent the invitation; however, three coordinators were excluded based on failed delivery of invitation, discontinuation of the programme, and duplicate invitations for one programme. Therefore, the final number of potential respondents was 41.

A total of 25 responses were received but one was excluded from the analysis due to insufficient data. For one programme (Bachelor of Nursing/Bachelor of Midwifery (double degree)) the survey was completed by two respondents (the overall coordinator of undergraduate degrees in that school and the course coordinator of the double degree). As the survey was intended to have only one response from each programme, only the response from the coordinator of the double degree was included in the analysis.

Table 7.1 shows the number of respondents and the details of programme type and frequency. The final response rate of the survey was 56.1% (23 of 41). One of the included survey respondents coordinated both undergraduate and postgraduate programmes at their institutions, while the remaining respondents each represented a single programme. Twenty- four accredited programmes were included, representing 48% of the programmes originally listed on the NMBA list. To preserve anonymity, the respondents were not asked to identify their university.

133

Table 7.1: Overview of the respondents and included programmes n of coordinators and n of invited coordinators programmes included and accredited % in the study programmes in 2012 Respondents 23 41 56.1 Programmes 24 50 48.0 Undergraduate 14 23 60.9 Bachelor of Midwifery 11 Bachelor of Nursing/Bachelor of 3 Midwifery Postgraduate 10 27 37.0

When asked if midwives had a professional role in educating pregnant women about nutrition, all except one of the course coordinators responded ‘yes’ (95.7%, n = 22). Of these course coordinators, the majority (63.6%, n = 14) thought this role was ‘very significant’, 22.7% (n = 5) rated it as ‘moderately significant’, and 13.6% (n = 3) rated it as ‘significant’.

The majority (91.3%, 21 of 23) of the respondents considered nutrition in midwifery curriculum and nutrition education during pregnancy for midwives in clinical practice to be important on some level with the same proportions (30.4% (n = 7) and 8.7% (n = 2)) rating them as ‘very important’ and ‘slightly’/‘not important’, respectively. Slightly over a third (34.8%, n = 8) rated nutrition in midwifery curriculum as ‘moderately important’, while 30.4% (n = 7) chose the same rating for nutrition education during pregnancy for midwives in clinical practice. The proportions that rated nutrition in midwifery curriculum and nutrition education for practising midwives as ‘important’ were 26.1% (n = 6) and 30.4%, (n = 7), respectively.

Sixteen coordinators representing 17 programmes provided a discrete number of hours allocated to general nutrition and/or nutrition during pregnancy while five provided an approximate range. Two coordinators did not provide a value or estimation. The number of hours spent in total on nutrition education during their programmes ranged from 2 to 48 hours. Figure 7.1 illustrates the hours allocated to general nutrition and/or nutrition during pregnancy in midwifery curricula by programme type. Half of the programmes (11 of 22) had 5 to <10 hours of nutrition content (6 undergraduate and 5 postgraduate programmes). Three coordinators reported that <5 hours were allocated to nutrition in their programmes, and four reported 10 to < 15 hours or 15 or more hours of nutrition content. Only undergraduate

134

programmes had 15 hours or more of nutrition content (n = 4). Two programmes had designated nutrition units and these made up half of the programmes that had 15 hours or more (2 of 4).

Four respondents reported that, other than the stated hours, nutrition content was embedded within other subjects, and one respondent indicated that a new subject on nutrition was planned to be included in the curriculum. Reading/class exercises and academic assessments that included a nutrition focus were mentioned by two coordinators. Two other coordinators highlighted that students were likely to be exposed to education on nutrition during clinical placement. No significant association was found between hours allocated to nutrition and programme type.

100% 90% 80% 70%

60% 50% 40%

Percentage 30% 20% 10% 0% 5 to <10 10 to < 15 15 hours <5 hours hours hours or more Postgraduate programmes 9.1% 22.7% 9.1% 0.0% Undergraduate programmes 4.5% 27.3% 9.1% 18.2%

Postgraduate programmes Undergraduate programmes

Figure 7.1: Hours allocated to general nutrition and/or nutrition during pregnancy in midwifery curricula by programme type

All of the respondents indicated that midwives were involved in providing the nutrition content of their programmes. Five respondents indicated that dietitians or nutritionists were also involved in providing nutrition content. Six respondents identified other health professionals (such as scientists, nurses, and lactation consultants) as involved in providing nutrition content.

135

Table 7.2 shows the nutrition topics covered in the participating midwifery programmes. Various topics of nutrition during pregnancy were covered but there was less reported coverage of important topics such as ‘managing weight during pregnancy’ (16 of 23) and ‘nutrition assessment (e.g., reviewing diet for nutrition requirements of pregnancy)’ (15 of 23), while topics such as ‘nutrition and teenage pregnancy’ (11 of 23) and ‘nutrition during pregnancy and different cultural groups’ (10 of 23) were the least covered topics. It was also noticed that the coverage of topics of nutrition during pregnancy was reported more frequently in comparison to the coverage of topics of general nutrition.

No significant association was found between nutrition topics covered and programme type (undergraduate or postgraduate) or between nutrition topics covered and seeking experts’ advice to review programmes’ nutrition content.

More than half (60.9%, n = 14) of the coordinators indicated that nutrition content of their programmes was reviewed and updated on an annual basis, and, within the remaining programmes (39.1%, n = 9), it was reviewed every 5 years as part of the accreditation cycle. Three coordinators commented that the curricula were reviewed each semester or each time a subject was presented. Three other respondents commented that the content was updated continually as new materials and evidence became available. One coordinator stated ‘not specifically addressed — is embedded across subjects’.

Nearly three quarters (73.9%, n = 17) of the coordinators reported that the review of nutrition content of their programmes did not involve seeking input from other experts (either internal or external). Of those who identified input from experts was sought (n = 6), two had consulted a dietitian. A midwifery external advisory committee was reported by another coordinator as the experts involved in reviewing nutrition curricula. The survey did not include a specific item on barriers to consulting experts (including dietitians) for the development, teaching, and/or review of nutrition components of midwifery programmes; however, two respondents indicated that cost was a barrier.

136

Table 7.2: Topics covered in midwifery programmes of general nutrition/nutrition during pregnancy Topics Numbera % (1) Topics of nutrition during pregnancy Alcohol and pregnancy 23 100 Nutrition related issues such as managing nausea and vomiting 23 100 Nutrition during pregnancy. e.g., the role of folate, iodine or calcium 22 95.7 The healthy range of weight gain required for pregnant women 22 95.7 Nutrition for breastfeeding 21 91.3 Nutrition management of gestational diabetes 20 87.0 Food safety and preparation during pregnancy (e.g., listeria) 19 82.6 Managing weight during pregnancy 16 69.6 Nutrition assessment (e.g., reviewing diet for nutrition requirements of 15 65.2 pregnancy) Nutrition and teenage pregnancy 11 47.8 Nutrition during pregnancy and different cultural groups 10 43.5 (2) Topics of general nutrition General nutrition for special groups (e.g., vegetarians, vegans and 13 56.5 different cultural groups) General nutrient information, e.g., the role of nutrients, vitamins and 12 52.2 minerals in the body General food safety 9 39.1 General nutrition, e.g., prevention of chronic illnesses such as cancer 6 26.1 or heart disease Other b 3 13.0 a Multiple responses allowed b Other included: ‘obesity’, ’eating disorders’, and ‘diets of heart and kidney diseases’

7.5.2 Stage 2

Seven coordinators participated in the interviews; of these, four coordinated postgraduate midwifery programmes and three coordinated undergraduate programmes. Nutrition content was integrated in all postgraduate programmes and in one undergraduate programme, while the other two undergraduate programmes had designated nutrition units. One of the two programmes having a designated unit also had additional nutrition content integrated into other subjects. The designated unit for the other programme was specified as compulsory by the course coordinator.

Staged presentation of nutrition content was indicated by the coordinators according to: life stages related to pregnancy (i.e. preconception, pregnancy, and breastfeeding); according to the level of midwifery care delivered to pregnant women (i.e. normal, complex, and emergency); and/or within topics such as anatomy and physiology. The focus in the content tended to be clinical or problem-oriented (i.e. anaemia, malnutrition, obesity, and diabetes).

137

One coordinator who had integrated nutrition content pointed out that they did not have a separate topic/lecture for nutrition and it would come up in the discussion of other topics. This may imply that nutrition was not considered formally as part of the curriculum.

We cover a little bit of it when we’re talking about anaemia in pregnancy…. Yes…. I think that’s about it. And I might say that throughout the year we will discuss, you know, the foods that women will have to avoid when they are pregnant … especially the ones that causes listeria … that sort of comes up as a general discussion during lectures…. It is not a separate subject. (Coordinator Four - Postgraduate)

Another coordinator made a few assumptions about how students acquire nutrition knowledge. She assumed that nurses enrolling in midwifery programmes came with previous knowledge and that students would learn about nutrition when learning about antenatal care.

OK. Well, there is no unit specifically about food and nutrition in the midwifery course. Our course is a postgraduate diploma course and all of our students are Registered Nurses, so I guess in one way it’s assumed that they come to that course with quite a high degree of general knowledge about health, so that’s, I guess, a bit of a background.…they also learn about the antenatal care of a woman and so quite obviously that entails good health and good diet and it also looks at things like listeria and, you know, foods that they shouldn’t eat and the reasons behind that. (Coordinator Two - Postgraduate)

All coordinators considered the nutrition content to be important on some level compared to other topics or units within their programmes. However, this was expressed in different ways. The coordinators who had designated units considered the nutrition units as important as other units. They specified that presenting nutrition as a designated unit was a reflection of the level of this importance.

We … identified when we were developing our curriculum, the importance of nutrition and the understanding of same for our students … when working with women during pregnancy. So we actually have a whole unit, a 12 credit point unit, designated to nutrition in the midwifery programme. Alongside of this … with our units that cover normal pregnancy, birth, post-natal and high acuity, which is like very complex midwifery experiences, nutrition is dealt with at a unit level as well. (Coordinator Seven - Undergraduate)

138

Three coordinators considered nutrition to be very important. Two of those coordinators cited the integration of nutrition throughout the curricula as a reason, while one highlighted that teaching about nutrition should be in the context of woman-led care, where the student identifies and discusses nutrition issues specific to that woman instead of getting taught about specific nutrition topics.

I think it’s very important, nutrition is very important. But I think it’s very important that it’s woman-led and student-led rather than us stating students learn this, this, and this about nutrition. So we talk about the importance of when they’re discussing nutrition and food with a woman that the student finds out what’s important to the woman rather than, you know, going through a tick box thing that they’ve covered everything. (Coordinator Six - Postgraduate)

One coordinator indicated that nutrition was of moderate importance, while another indicated equal importance with other topics but admitted that time allocated to nutrition content did not reflect this status.

…out of the whole 3 years it’s talked about in Year 1, one lecture and two tutorials, that’s it…. That lets you know how important it is and if we don’t give it any more time than that, the students won’t see it as important. (Coordinator Five - Undergraduate)

For programmes with integrated nutrition content, the responsibility was fully that of the midwives (i.e. the coordinators or midwifery academics), with no or little involvement of other experts in the field (such as dietitians). Nutritional expertise was not requested, not considered necessary, nor could it be guaranteed.

In programmes with designated nutrition units, one unit was delivered by an academic who was also a dietitian; in the other, the expertise of the dietitian was acknowledged by involving them in teaching the unit. Dietitians as experts were called upon to deliver technical content that midwives were not comfortable or sufficiently skilled to deliver; however, their skills in teaching counselling or how to talk to women about nutrition were not fully used.

…what she [the dietitian] does is gives the … science behind why nutrition is important.…the reason I get a dietitian is because they have that in-depth knowledge of understanding what happens at the cell level and so on whereas as a midwife, I mean I understand it but I couldn’t teach it. I couldn’t answer the questions if they

139

were too curly for me, you know, whereas she can. (Coordinator Three - Undergraduate)

One coordinator assumed that diet is ‘straightforward’ in comparison to other issues. She also assumed that a programme would not pass accreditation unless it contained nutrition content.

…in most instances whatever the student is researching, whether it is domestic violence or whether… they’re looking at something as straightforward as diet… (Coordinator Two - Postgraduate)

Similarly, the curriculum development and review activities were midwifery driven and relied on the academic responsible for the content to keep up with the literature. In designated nutrition units, one unit had a nutritionist as an assessor. The development and review activities were easier to identify and report. Two coordinators admitted nutrition content did not get reviewed as it was integrated. One of these coordinators reflected that reviewing nutrition content and evaluating how it is taught might be an idea worth considering in the future to assist in preparing students for their role in providing nutrition advice.

No coordinator reported professional or theoretical models as informing their nutrition content, in contrast to the use of such models to support breastfeeding (as was pointed out by two coordinators). Some respondents were not aware of any national midwifery support or guidance in relation to nutrition content.

Well, no [professional or theoretical models to inform nutrition content]. I’ll tell you in the module, in our tutorials outline we always put in the ANMC [Australian Nursing and Midwifery Council] Competencies Standards for the Registered Midwife… they’re listed so that the student knows that’s what they’re supposed to be doing … and all that talks about in there, the closest one that would go anywhere … related to nutrition is competency 5, element 5.1 assess the health and well-being of the woman and baby. So there’s nothing really that underlines how we teach about nutrition, it’s what we find in the textbooks or our midwifery readings and that’s it. (Coordinator Five - Undergraduate)

Coordinators identified specific aspects of the nutrition education within their programmes which would help their students to provide nutrition advice to pregnant women. Some of these aspects included the content itself, how the materials were presented (designated or

140

integrated), the nature of the course (e.g., inquiry based) and the clinical placement including continuity of care.

Most coordinators reported using governmental guidance such as the National Health and Medical Research Council (NHMRC) dietary guidelines and reference values. However, in two instances, this was undertaken by just giving the brochures to the students. One coordinator reported that there was no teaching about dietary guidelines within their programme as students are registered nurses and were assumed to have previous knowledge. Another coordinator assumed that a hospital dietitian would be the source of up to date information for the students.

No. No. I wouldn’t say we [follow any national standards] ... as I said, the dietitian at the hospital actually, we presume, has the most up to date information and that’s what will be discussed with the women in any case … we will sort of follow the lead of the dietitian but, we ourselves, I wouldn’t say we actually go seeking that kind of information because we don’t actually have a topic that looks at nutrition into detail. (Coordinator Four - Postgraduate)

Overall, there was a lack of adoption of approaches that would specifically teach the students how to assess women’s nutrition requirements or advise them about achieving such requirements in the programmes included in the study. However, one coordinator indicated that their programme used ‘motivational interviewing’ as a way of working with women who have lifestyle issues (e.g., obesity or smoking). Another one cited a class activity about altering a menu. Three coordinators mentioned that nutrition may be involved in some standard practices as part of caring for women (e.g., practising booking a visit, and case studies). Three assumed students would develop those skills during clinical placement, although, it was indicated that student exposure to nutrition education during clinical placement could not be guaranteed. There was a concern that any such exposure during placement would be generally problem-oriented and could be based on stereotyping.

…There’s also a part of the course where students look after women in a continuous way called continuity of care … the student would speak to the women, would educate the woman in a very non-structured way in the form of really focused care about her, so I feel that if the student was looking after a woman that was very well educated and very healthy and that had enough money to buy food and that was in a secure relationship that … [the student] probably wouldn’t spend a lot of time talking to

141

them about good nutrition because they would probably be looking at that woman and saying, this woman understands about good nutrition and it would be approached in a circumspect way. But if on the other hand they were looking after someone who had very little money and who … didn’t have support then … they would take on that role, they would see that as a much more important part of what they do, if that makes sense. (Coordinator Two - Postgraduate)

All the coordinators thought that the graduates from their programmes would be generally prepared to provide nutrition advice at a basic level to pregnant women. However, one coordinator indicated that a deep understanding of the short and long term effects of nutrition on the health of mother and offspring would be lacking.

Some coordinators believed that knowledge of principles such as consultation and referral and woman-centred care would be sufficient preparation for providing nutrition advice at a basic level to pregnant women. Only one programme had formally evaluated their nutrition unit. They obtained positive feedback from their students.

I believe they’d be excellently prepared in that,… they would be following the principles of woman-led care, they’d be following the principles of consultation and referral, so if there was a woman with specific needs, most of the units have a dietitian that they could refer to and seek advice from … we are graduating midwives, woman-centred, evidence-based midwives, as far as consultation and referral goes that they would know when further expert advice was needed. (Coordinator Six - Postgraduate)

The coordinators provided mixed responses when asked about barriers and facilitators within programmes that may hinder or help students to learn to provide nutrition advice. Some participants said that there were no barriers or they were unable to identify specific barriers but then supplied in their description of facilitators an indication of their course inadequacy; or they named specific barriers but then implied that they were ‘doing enough anyway’. Some identified barriers included a lack of a separate nutrition topic (due to lack of time), a lack of face to face interaction, and a lack of a dietitian’s involvement. Conversely, their opposites were some of the facilitators. One coordinator mentioned that their programme had no barriers as she believed midwives were not ‘dietitians’, while another one thought that the midwifery academics were professionals who kept themselves up to date with the necessary information.

142

No[barriers], not really...we could get a dietitian in to talk to the students but their contact time is limited and I think that the level of knowledge that the students need to impart to the pregnant women … should be well enough covered by the experienced academics that teach them … those academics … all of the information that they teach, is informed by research … it’s not storytelling, so they are looking into … texts that are written and best evidence with published papers in order to prepare the lectures that they give to students and the content that they provide. (Coordinator Two - Postgraduate)

One coordinator indicated that graduating midwives might face barriers such as a poor model of care (i.e. the model fails to allow sufficient time which leads to the provision of problem- oriented nutrition advice). On the other hand, another coordinator acknowledged that factors such as in-service education sessions for midwives with dietitians could help practising midwives provide quality nutrition advice.

Some coordinators commended the current research, with one stating it highlighted the gaps in their curriculum and its clinical focus.

I think this [current research] is a good thing…to go through and look at what my colleagues are teaching our students because there are other people who contacted me with similar kinds of studies on other various things in our curriculum and it really highlights when you do this, what is not in our curriculum. And I think curriculums are still basically focused on disease processes. So even though midwives say we’re all about well and healthy and supporting women that’s not what we’re spending our 3 years teaching students. (Coordinator Five - Undergraduate)

7.6 Discussion This study found that Australian midwifery course coordinators considered nutrition education in midwifery curricula and the role midwives can play in this area as important. However, this was not reflected in the nutrition content of the programmes. Nutrition components were included in all programmes represented by survey respondents but hours allocated to nutrition were generally low and topics covered varied. Only two programmes had designated nutrition units. Dietitians were not often involved in teaching nutrition and few programmes involved experts in the review of their nutrition curricula. The interviews revealed that nutrition education tended to be problem-oriented and at times based on various assumptions. Nutrition content was not informed by any professional or theoretical models. 143

The development of nutrition assessment skills or practical training for midwifery students in the provision of nutrition advice was lacking.

The variable and few hours allocated to nutrition and small numbers of programmes having designated units are comparable with findings from international research (Touger-Decker et al. 2001, McNeill et al. 2012). In the United Kingdom’s (UK) midwifery programmes, hours allocated to ‘maternal nutrition’ and ‘obesity/weight management’ topics within public health curricula were fewer than 10 hours and these topics were mostly integrated into the curricula (McNeill et al. 2012). When nutrition is integrated across subjects, it could be perceived as less important and therefore not emphasised as it should be in practice (Adams et al. 2010b). It would also be more challenging to review coverage of core nutrition topics. In contrast, its importance is highlighted when nutrition is presented as designated units, as was identified by some coordinators in this study. From a practical perspective, having nutrition as a stand- alone unit in all midwifery programmes might not be feasible, particularly in postgraduate programmes, where the length of the programme (from 12 to 18 months) might be a challenge. With the challenge of a crowded and ever-expanding curriculum in the education of health care professionals, there is an increased trend for nutrition content to be integrated rather than presented separately (Adams et al. 2015). This integration could be considered as a strength if it is done effectively, as it reflects the complexity of practice, where nutrition is rarely discussed in isolation (Adams et al. 2015). However, interviews with midwifery coordinators identified that nutrition education integrated across the curricula tended to be problem-oriented and at times inconsistent and based on various assumptions. These assumptions included: nursing students’ existing nutrition knowledge, students’ exposure to nutrition while learning about antenatal care, inclusion of nutrition in accreditations standards, ease of dietary behavioural change, and students’ exposure to nutrition during clinical placement. This may be due to the absence of clear national midwifery guidelines on the way nutrition should be included in the curriculum and the absence of specified competencies on what knowledge and skills the students need to acquire (Arrish et al. 2014). It is at the discretion of each institution.

Generally, nutrition education in health care professionals’ education has been identified as inadequate (Kris-Etherton et al. 2014), even in those professions such as medicine (Adams et al. 2006, Adams et al. 2015), which have received more attention compared to nutrition education within the midwifery discipline. An inability to fit nutrition within crowded curricula is one of the main reasons given for this omission (Adams et al. 2015). The failure

144

of professional education to equip graduates to face the evolving challenges in the health care system has also been linked to curricula being ‘fragmented, out-dated, and static’ (Frenk et al. 2010 p. 1923). Several strategies have been identified that might increase integration of nutrition into health care professionals’ education, including: introducing mandatory policies and legislation; adopting new approaches in the education of health care professionals (e.g., emphasising a competency-based curriculum and utilising information technology in the teaching process); and emphasising a mandatory inter-professional team-based education (including, defining the specific roles of each discipline in nutrition education) (Kris-Etherton et al. 2014).

The tendency of the nutrition content to be focused on problems or medical issues may be attributed to the medicalisation of pregnancy (Johanson et al. 2002) and high prevalence of obesity and other pregnancy related complications (McIntyre et al. 2012), which may have led to the change of midwifery from being a health and wellbeing promoting profession to a one being more focused on risk and disease management. In a survey of more than 300 Australian midwives, around 60% indicated that they provided nutrition advice only if the pregnant woman had a medical issue and 24% did that only if the woman asked questions (Arrish et al. 2016a). In the current study, the importance of nutrition being taught in the context of woman-led care was referred to, as was the possibility of the medical or problem- oriented focus of nutrition education provided to students during clinical placement and the probability of students stereotyping women when providing nutrition advice (the last two somewhat problematic). According to the philosophy of the Australian College of Midwives (ACM) (2004), midwives provide woman-centred care where they work in partnership with women and focus on women’s specific health needs, expectations and aspirations. However, caution needs to be taken not to wait for women to initiate the conversation about diet or base the advice on assumptions related to women’s socio-economic status as recent research indicated low levels of nutrition knowledge and adherence to dietary guidelines among pregnant women in spite of the majority having high level of education, motivation and perceived confidence in adopting a healthy diet (Bookari et al. 2017). The authors of the study suggested that women’s mistaken beliefs in their ability to eat healthily might prevent them from seeking nutrition information from health professionals (Bookari et al. 2017). Midwifery education needs to highlight the midwife’s role in public health, especially in the area of nutrition. This might encourage midwives to become more proactive and offer the

145

opportunity to every woman to receive appropriate nutrition advice, not just when questions are asked or medical issues are present.

Most of the nutrition teaching was done by midwives. With the reported inadequacy of nutrition education for midwives, their carriage of the nutrition topics within the curricula could be quite variable. Dietitians/other nutrition experts were rarely involved in teaching or reviewing the nutrition content as their expertise was not requested or considered necessary or could not be guaranteed. Studies in medical education have reported similar findings (Adams et al. 2010a). Even when the expertise of a dietitian was involved and acknowledged, their knowledge in the area of behaviour change was not fully used. Practical training on how students can assess pregnant women’s nutrition requirements and provide advice to meet these needs was generally lacking. Dietitians/nutritionists are ‘university-qualified experts in nutrition and dietetics’ (Dietitians Association of Australia 2017) and their input into the education of other health professionals could be considered highly relevant. Kris-Etherton et al. (2014) argued that nutrition education for health professionals needs to be based on a team approach and that dietitians need to be involved not only in the teaching of the content but also in the planning process. Including nutrition experts in the review process of nutrition content might provide some quality oversight and ensure that the curricula were in line with rapidly occurring changes that characterise scientific subjects such as nutrition generally and nutrition in pregnancy specifically. The cost and limited availability of dietitians/other nutrition experts were indicated as barriers. Strategies to consider would be collaboration with nutrition educators from the same universities and/or dietitians from community or hospital settings. The development of an online nutrition module by dietitians and other nutrition experts that could be made available to all Australian midwifery programmes is an alternative strategy worth considering. This strategy has been previously implemented in the discipline of medicine (Adams et al. 2010a).

A wide range of nutrition topics was reported to be covered in the surveyed programmes. However, there was less focus on topics involving practical or management skills such as ‘nutrition assessment (e.g., reviewing diet for nutrition requirements of pregnancy)’ and ‘managing weight during pregnancy’ compared to other topics involving more theoretical knowledge. These findings are consistent with the results of previous international research (Elias and Green 2007, McNeill et al. 2012). Equipping midwives with theoretical nutrition knowledge is essential, but so is equipping them with practical or management skills to apply this knowledge, in particular the skills to manage weight gain during pregnancy. This is imperative with the high prevalence of maternal

146 obesity in Australia negatively impacting on the health of pregnant women and their babies (McIntyre et al. 2012). Australian midwives have previously cited lack of adequate education in the areas of gestational weight gain (Willcox et al. 2012) and maternal obesity and how to manage them (Wilkinson and Stapleton 2012) as a reason for not giving advice (Willcox et al. 2012). This is supported by the findings of our study which indicated that the topic ‘managing weight during pregnancy’ was covered by a low proportion of the surveyed programmes.

The two topics of nutrition during pregnancy that were least well covered in the programmes were ‘nutrition during pregnancy and different cultural groups’ and ‘nutrition and teenage pregnancy’. These two groups of women are more likely to be at risk of suboptimal nutrition status during pregnancy (Baker et al. 2009, Higginbottom et al. 2014). Australia is a multicultural society and it would be anticipated that midwives regularly care for individuals from different cultural and linguistic backgrounds (Williamson and Harrison 2010). Australian midwives were found to have low to moderate levels of confidence in advising this group of women about diet (Arrish et al. 2016a). Pregnant teenagers are a vulnerable group and have high nutrition demands (Williamson 2006). This group also needs to be given specific attention by health professionals, especially as previous research has indicated that they consider the health professionals as their most trusted source of healthy eating information (Wise and Arcamone 2011). More coverage of these important topics in midwifery curricula is recommended.

Contrary to their acknowledging nutrition as important, none of the coordinators interviewed identified lack of clear practical approaches to assess women’s diet or provide nutrition advice in view of that assessment as barriers. This is in contrast to the ICM (International Confederation of Midwives 2010) core competencies which clearly articulate that midwives’ competency in the provision of nutrition advice to pregnant women needs to be based on both knowledge and skills. The National Competency Standards for the Midwife are considered essential in determining what is involved in the midwifery curriculum as it is usually mapped against the standards (Australian Nursing and Midwifery Accreditation Council 2014). Therefore, nutrition or promotion of healthy eating needs to be included in these competency standards. Such standards would make nutrition education consistent across midwifery programmes, so that all midwives would have basic knowledge and skills which might translate into the provision of consistent nutrition advice.

147 Other policies place expectations on midwifery programmes to review their inclusion of nutrition within their curricula. The Standards of Maternity Care of Australia and New Zealand (revised in 2016) (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014) state that information about nutrition and diet should be offered by health professionals to pregnant women at the first contact. Additionally, the recently released clinical antenatal guidelines (models one and two) (Australian Health Ministers’ Advisory Council 2012, Australian Health Ministers’ Advisory Council 2014), which are intended for all antenatal care providers, outline key nutrition related issues in pregnancy, and the nature of the information that should be provided.

7.6.1 Limitations and strengths

Limitations of this study need to be considered when interpreting the findings. The survey was completed by 23 of 41 coordinators and thus the results do not reflect the nutrition content of all Australian midwifery programmes. However, the results reflect 48% of accredited programmes in 2012 and are therefore likely to reflect common practice and professional expectations of practice. It could be that the study respondents represented coordinators with more nutrition-oriented programmes and the non-responding coordinators had even lower coverage of nutrition in their programmes. Another limitation is the self- reporting of curriculum content; most of the coordinators acknowledged that their estimation of hours allocated to nutrition was approximate. Identification and quantification of nutrition content can be challenging especially when it is integrated throughout the curriculum. However, estimation is a common method of quantifying hours allocated to nutrition in the literature (Touger-Decker et al. 2001, McNeill et al. 2012). Despite repeated invitations for interviews, only seven coordinators agreed to participate. The number is small and, therefore, it is unlikely that data saturation was reached. However, participating coordinators were from both undergraduate and postgraduate programmes (with either integrated content or designated nutrition units), providing varied perspectives on nutrition education within these programmes. A strength of this study is that it is the first to explore the nutrition content of midwifery curricula in Australian universities. The mixed-methods approach is another strength, where the interviews provided a deeper insight into midwifery coordinators’ perspectives on the nutrition content within their programmes.

148 7.6.2 Future research

In the future, document analysis could be considered by an ‘authoritative’, independent agency so as to maximise access to useful course materials for more accurate evaluation of hours and nutrition content. Prospective studies should explore newly graduated midwives’ nutrition knowledge and their preparation for providing nutrition advice to pregnant women. Some of the course coordinators indicated that students would be exposed to more nutrition information and practical training in nutrition during clinical placement. Further research would be required to determine the extent of nutrition education acquired by midwifery students during clinical placement. The process of midwifery curricula review and how it affects the integration of nutrition content into the curricula would be a key area of future research. Also needed is examination of effective strategies to integrate nutrition education into midwifery programmes.

7.6.3 Implications for midwifery education

The Australian clinical antenatal guidelines and the Standards of Maternity Care of Australia and New Zealand (Australian Health Ministers’ Advisory Council 2014, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014) indicate the need for minimum requirements of nutrition to be included in Australian midwifery education and the inclusion of nutrition knowledge and skills as core competency areas in Australian midwifery competency standards. This may be achieved through consultation and collaboration between nutrition experts, midwifery educators, and professional midwifery bodies such as the ANMAC. Practising midwives and pregnant women need to be also included in such consultations. The findings of this study also have implications for course coordinators of midwifery programmes in other countries, as similar studies have rarely been undertaken.

7.7 Conclusion Pregnant women need to receive relevant, timely, and accurate information to prevent excess weight gain and to maximise their nutrition-related health and that of their babies. Midwives have a unique role to play in educating pregnant women about their diet and its effects on their health and the health of their children. Graduate midwives need to be prepared, through their education, to fulfil this role. In order to meet new clinical antenatal guidelines and standards of maternity care, midwifery education in Australia needs to reconsider its

149 coverage of nutrition to maximise midwives’ ability to provide appropriate nutrition advice to pregnant women.

7.8 Competing interests The authors declare that there are no competing interests regarding the publication of this paper.

7.9 Acknowledgements This research received funding from the Libyan government as part of a doctoral scholarship for (Jamila Arrish). The Libyan government had no role in the study. The authors express their appreciation for all midwifery coordinators who completed the survey and participated in the interviews. The authors also thank: Ms. Cheryl Jecht for her assistance in transcribing the interviews; Dr. Alexis St. George for her valuable feedback on the early draft of this paper, and Ms. Elaine Newby for her assistance in the editing process.

150

8 OVERALL DISCUSSION AND CONCLUSION

8.1 Preface This chapter provides an overall discussion of the findings generated by the studies undertaken to explore midwives’ nutrition knowledge in relation to providing information to women in the childbearing continuum and the nutrition content within midwifery programmes. The chapter commences with an overview of the existing literature and the thesis aim and questions followed by the presentation and integration of the findings (according to mixed methods design). How the thesis answers the research questions is presented. The significance of the results and how this contributes to the body of knowledge are provided and the limitations and the strengths of the studies are also summarised. It concludes with a final statement, recommendations to improve clinical practice and nutrition education within midwifery education, and suggestions for future research.

8.2 Introduction Maternal nutrition during pregnancy has significant short and long term implications for the health of the mother and the foetus. Most pregnant women do not meet dietary recommendations (Malek et al. 2016) and many do not receive nutrition advice (Lucas et al. 2014a) despite being perceived as receptive to nutrition messages (Szwajcer et al. 2005). Midwives are ideally positioned to provide nutrition advice during pregnancy as they usually have contact with pregnant women. According to the ICM core competencies (International Confederation of Midwives 2010) , midwives are expected to have the knowledge and skills to assess maternal nutrition and provide nutrition advice accordingly. However, there is limited literature, especially in Australia, about midwives’ role in this important area (Arrish et al. 2014). This thesis aimed to explore the role of midwives in providing nutrition advice, their nutrition knowledge, and the nutrition education in midwifery programmes using a mixed methods design incorporating surveys and interviews with both Australian midwives and the coordinators of midwifery programmes in Australia. The specific questions this research addressed were:

1. What are midwives’ attitudes towards the importance of nutrition during pregnancy and the significance of their role in providing nutrition advice? What are midwives’ confidence levels in providing general and specific nutrition advice?

2. What nutrition education do practising midwives receive during their pre-registration education or while practising? What nutrition topics are included in the received

151 education? Who provides such education?

3. What are the perceptions of midwives regarding their professional role in providing nutrition advice during pregnancy? How does the model of midwifery care affect midwives’ provision of nutrition advice? What are the barriers/factors that midwives consider act to hinder or facilitate inclusion of nutrition education in their professional roles?

4. What are the food and nutrition content and skills being taught in midwifery programmes in Australia? How many hours are allocated to nutrition content within the curricula? Who is responsible for teaching and reviewing the nutrition content? What are the views of the course coordinators of the nutrition education within their programmes and the midwife’s role in providing nutrition advice?

5. How can nutrition curricula in Australian midwifery programmes be improved?

6. How can midwives be assisted to integrate nutrition education into their practice?

Clear answers to these questions were successfully obtained. The majority of Australian midwives believed nutrition during pregnancy was important and they had a key role in promoting nutrition during pregnancy, but most had significant knowledge gaps and were not confident discussing nutrition with pregnant women. These findings were not surprising as only half reported receiving nutrition education during their basic or midwifery education or during practice. This education was described by the midwives as limited and lacking focus on key contemporary issues. The midwives undertook personal initiatives to address this information gap. Nutrition was taught within all midwifery programmes surveyed but the education was limited by its low number of hours and the tendency to be problem-oriented and based on various assumptions. Midwives perceived their role in providing nutrition advice to pregnant women as a vital part of their practice but many barriers restricted the expansion and the efficacy of this role. Collaboration with nutrition experts was lacking, as was the development of nutrition assessment skills or practical training for students in the provision of nutrition advice.

This research had not been undertaken previously in Australia. The findings provide insights into professional nutrition education for one of the leading health care professionals, midwives. Improvements in nutrition education of midwives are important as they are at the

152 front line of providing health advice to pregnant women, which may not only impact on women’s health but also on their babies’ and families’ health in the short and long term.

8.3 Summary and integration of the findings Answering the first research question, the results of the first Study (Chapter 4) indicated that midwives believed in the importance of nutrition during pregnancy and the significance of their role in providing nutrition advice to pregnant women. Study 2, answering the third research question (Chapter 6), provided more understanding of midwives’ perceptions of the nature and extent of this role. Midwives perceived providing nutrition advice to pregnant women as a vital part of their practice and they generally agreed they are the first point of contact in terms of delivering nutrition information. However, they acknowledged they were by no means the experts.

Consistent with their views that their nutrition education role was ‘very significant’, the majority of midwives reported they provided nutrition advice to pregnant women (Chapter 4). However, the focus and nature of this advice was not consistent with the ‘very significant’ view of their role. The advice was frequently referred to as being ‘basic’ or ‘general’ and covered topics such as healthy eating, micronutrients, and food safety, with few midwives providing advice about weight management. The interviews with the midwives confirmed this classification of their advice as being ‘general’ and ‘basic’, especially in the context of health promotion. Many of the midwives followed a passive approach in the way they conveyed nutrition information, especially to the women they perceived to be healthy. The advice of many midwives was mostly medically directed, given when suspecting a deficiency or managing an issue, and not focused on promoting health (Chapter 6).

Explanations for these inconsistencies between the perceived importance of their nutrition education role and how it was actually delivered could be attributed to the barriers midwives discussed as impeding their role in providing effective nutrition advice. Model of care, lack of time, and lack of relevant and reliable resources were the most discussed barriers that restricted the extent of the role of midwives in this important area (Chapter 6). Interestingly, the data indicated that midwives in public hospitals had lower mean scores of nutrition knowledge compared to independent midwives (Chapter 4). This finding in part was explained by the accounts of midwives (especially in public hospitals) that they lacked time, and this not only restricted their provision of nutrition advice but also impacted on opportunities to update their nutrition knowledge.

153 The midwives had inadequate nutrition knowledge in several areas and variable levels of confidence in discussing general and specific nutrition issues. One possible explanation for this is that midwives received minimal nutrition content during midwifery education and during practice. The analysis of the nutrition education received by the midwives (in midwifery education and/or during practice) reported in Chapter 5 (answering the second research question) revealed that this education was generally limited and focused on basic concepts. The education lacked focus on important skills or issues, such as nutrition assessment, weight management, nutrition for vulnerable groups such as adolescents and women from diverse cultural-linguistic backgrounds. Continuing education was reported to occur mostly through personal initiatives by the midwives as they attempted to fill the gaps in formal education (Chapter 5). Midwives’ accounts in the interviews (Chapter 6) confirmed the limited availability of continuing education opportunities for midwives in Australia, especially about nutrition generally. Midwives also highlighted that a midwife would need to be highly interested and motivated to seek such education. To facilitate midwives’ provision of better nutrition advice, they suggested continuing education or regular updates from reliable sources, which may reduce the over reliance on self-directed learning.

Dietitians were the most used source of nutrition information for the midwives (Chapter 4); however, the midwives highlighted limited availability of referral to dietitians’ services for issues other than gestational diabetes and, to a lesser extent, obesity. One of the most frequently mentioned facilitators to help midwives provide better nutrition advice as suggested by the midwives themselves was collaboration with dietitians (Chapter 6). Midwives suggested dietitians be involved in antenatal care on a regular basis and participate in providing education for both pregnant women and the midwives (Chapter 6).

The course coordinators were in agreement with midwives in regard to perceiving their role in providing nutrition advice as important. Similarly, they viewed nutrition education in midwifery education as important (Chapter 7, answering the fourth research question). They all reported that nutrition content was included in their midwifery programmes. However, half of the programmes were reported to have only from 5 to <10 hours on nutrition, while two had a designated nutrition unit. The interviews revealed that nutrition education tended to be problem-oriented and based on various (sometimes erroneous) assumptions. Some coordinators reported a lack of national midwifery guidelines on teaching or assessing nutrition education. Midwives also indicated they lacked midwifery specific guidance in regard to nutrition (Chapter 6).

154

It was noted that the pattern of nutrition topics as reported by the coordinators within their midwifery programmes (Chapter 7) were similar to the pattern of topics as reported by the midwives in Chapter 5. Fifty-seven per cent of the midwives were aged 41 and older, thus they may have received their midwifery education some time ago and 50% of the midwives reported they had gained their education through hospital-based training rather than through the more recently implemented pathway of university education (Chapter 4). This may imply little change in the pattern of nutrition topics covered within midwifery education. It may not reflect the changes in nutrition knowledge and advances in the understanding of the importance of nutrition during pregnancy, or the changes in midwifery practice, such as increasing numbers of women with obesity or diabetes, or the greater diversity of vulnerable women. The coordinators considered that graduate midwives from their programmes would be prepared to provide nutrition advice on a basic level despite the lack of development of nutrition assessment skills or practical training for students in the provision of nutrition advice (Chapter 7).

8.4 Significance of the research The findings of this thesis have important implications that may support Australian practising midwives to provide better nutrition advice to pregnant women which may enhance pregnant women dietary behaviour and impact positively on their health and the health of their babies in the short and long term. The findings also have direct implications for nutrition education within Australian midwifery programmes that can also be applicable to midwifery education in other countries.

Overweight and obesity rates are increasing among childbearing women in Australia (Australian Bureau of Statistics 2013) and consequently are impacting negatively on pregnancy and foetal outcomes (McIntyre et al. 2012). This impact might not be only in the short term but also for the long term. If the government is serious about tackling the significant issue of maternal obesity, the issue needs to be a priority. This research, through going back to basics about what support is being provided to women to address nutrition related issues, has highlighted a significant flaw in the provision of health services. Health professionals are not being equipped to address contemporary health issues in a proactive manner, both through developing an adequate knowledge base and also the provision of effective strategies to incorporate into professional practice. This study has highlighted the issue with midwives, a key health professional with influence on women’s health during a significant life stage. This raises a concern about other antenatal care providers and their 155

preparation to effectively deal with contemporary health problems during pregnancy. There is generally more focus on addressing pregnant women’s behaviour in terms of obesity and weight management and less focus on changing health professionals’ behaviour in these issues or addressing the barriers that prevent them from providing effective counselling in these areas (Heslehurst et al. 2014).

The current research indicates the inadequacy of midwives’ nutrition education not only during midwifery education but also during practice. The education is primarily in the remit of the professional group itself, who may be perpetuating past practices, rather than reflecting on the need for new approaches to professional education to tackle contemporary health problems. If this situation continues without any serious action from the government or health services, it will create a continuous cycle where health care providers are not provided with adequate support and education. This will lead to a further lack of knowledge and skills and consequently a provision of insufficient nutrition advice or a failure to provide advice at all. This in turn may impact negatively on the health of the mother, the foetus, and future generations.

8.5 Contribution to knowledge The studies included in this thesis provided new evidence and insight about the role of health professionals, namely the midwives, in providing nutrition advice during pregnancy. There was limited literature about this area prior to conducting this research, especially in Australia (Chapter 2.3). The published literature review identified the gaps and areas requiring further investigations. Identified gaps were the key areas that formed the basis of this thesis.

To the knowledge of the student researcher, Study 1 (Chapter 4) was the first quantitative study to assess Australian midwives’ general nutrition knowledge, their attitudes, and confidence in providing nutrition advice during pregnancy and to identify the gaps in these areas which were in agreement with previous international findings. Identifying the gaps in midwives’ knowledge and the areas where midwives have low levels of confidence in discussing nutrition issues with pregnant women makes a significant contribution to public health educational initiatives aiming to improve midwives knowledge and confidence. Targeting those gaps when planning nutrition educational interventions for midwives may encourage and help them to provide effective nutrition advice. This in turn may impact the health of the mothers in a positive manner. Effective lifestyle and nutrition advice is a cost- efficient and harm-free way to reduce gestational weight gain and its complications.

156 Additionally, the findings related to nutrition education received by midwives during midwifery education and during practice as presented in Chapter 5 could be considered new knowledge as midwives’ nutrition education has been the focus of little research. The chapter highlighted the shortcomings of both areas of education and pointed out midwives’ needs for nutrition education about contemporary issues and topics such as weight management, nutrition assessment and diets for at risk groups which could be reinforced in both midwifery curricula and in future educational interventions to support midwives in the provision of effective nutrition advice and care for these groups.

Chapter 6 provided important insight and understanding to midwives’ professional practice in the area of nutrition and how they perceive the nature and extent of their role in regard to the provision of nutrition advice to pregnant women and how the model of care affects the way they provide such advice. It indicated that midwives’ practice in this area is largely restricted and challenged by a number of barriers. The midwives suggested a number of important facilitators that may help them overcome the barriers and improve their role as nutrition educators. This study added to the body of evidence reporting health professionals’ limited provision of nutrition advice due to perceived barriers. The facilitators suggested by the midwives are important and need to be taken into consideration by governmental agencies, health services, and professional bodies that aim to expand the involvement and the effectiveness of the midwives’ role in improving dietary behaviours of pregnant women.

The final study (Chapter 7) which investigated nutrition education within midwifery education provided a novel insight into this subject as previous research in this area has rarely been conducted. It highlighted the gaps in nutrition education in current midwifery programmes. These include: the low numbers of hours allocated to nutrition education for midwives, the too great focus on providing theoretical knowledge and too little focus on developing skills, the inadequate practical training, lack of collaboration with nutrition experts, and lack of clear professional standards and nutrition competencies domestically. These identified gaps provide an indication to midwifery educators of the areas that need to be targeted to provide better nutrition education to future midwives. The study also provides recommendations on how these gaps can be filled.

8.6 Limitations and strengths There are some limitations of this research that need to be noted. The participants for Study 1 (Chapters 4 and 5) were recruited through the ACM, but the College does not include all

157 Australian registered midwives. Therefore, the sample cannot be representative of the general population of Australian midwives although it was similar in terms of gender and age (Australian Institute of Health and Welfare 2013).

Despite repeated email invitations, the response rate for the midwives’ survey (7%) was low although it is not unexpected for online surveys to have low response rates (Yetter and Capaccioli 2010). The sample size was estimated to achieve sufficient statistical power and the number of responses obtained was close to the estimated sample. The interviews had also generally low response rates (n = 16 midwives and n = 7 coordinators). While data saturation was achieved from the midwives’ interviews, it was questionable with the coordinators’ few interviews. However, the interviews might have been successful at presenting basic themes. According to Guest et al. (2006), interviews as few as six are adequate for extracting basic elements while twelve would be enough for reaching saturation. A key strength was that the midwives’ interviews included midwives from different models of care and the coordinators’ interviews included coordinators from undergraduate and postgraduate programmes with programmes providing both designated nutrition units and integrated nutrition curriculum. This provided various perspectives and insights to the data.

The midwives’ knowledge survey was neither validated nor comprehensive. Knowledge was one component of the framework of the thesis not the main one. The survey was kept short based on the feedback from the pilot study. The survey provided a snap shot of the midwives’ knowledge which was inadequate in several areas.

The voluntary nature of participation in this research may imply that only more nutritionally- oriented midwives and coordinators took part. This may suggest that non-participating midwives might have even lower level of knowledge and confidence, and non-participating coordinators might have even lower coverage of nutrition within their curricula.

The mixed methods approach used in the studies of this thesis with the same sample of both midwives and coordinators is a strength. Findings from the quantitative surveys could be explained and clarified by rich data from the qualitative studies.

This study was exploratory in nature due to the limited quantity and quality of prior literature. The conceptual framework underpinning the thesis (chapter 3, Figure 3.2 p. 43) was focused on exploring the variables affecting the midwives’ behaviour of providing nutrition advice. It incorporated both personal variables (i.e. knowledge, attitudes, confidence and role

158 perceptions) and environmental and structural factors (such as professional nutrition education, the model of care utilised, and the barriers and facilitators).

The relationships between the midwives’ mean score of nutrition knowledge and their attitudes, received nutrition education, and confidence were investigated in a quantitative manner (Chapter 4). The framework confirmed the significant relationship between midwives’ mean score of nutrition knowledge and the receipt of professional nutrition education during midwifery education, and the significant relationship between midwives’ mean score of nutrition knowledge and their confidence in providing general nutrition advice. However, no association was found between midwives’ score of nutrition knowledge and their attitudes towards the importance of nutrition during pregnancy and the significance of their role in providing nutrition advice. The reason for such findings might be that although previous literature indicates an association between knowledge and attitudes, this association is usually weak (Bettinghaus 1986). The presence of positive attitudes does not always lead to better knowledge. Factors like professional nutrition education might have greater effect on knowledge. However, there is limited literature reporting on nutrition education interventions aiming to improve midwives’ nutrition knowledge (Barrowclough and Ford 2001, Basu et al. 2014). More focus on this area is needed.

Positive attitudes might not lead to practice as well. Midwives in the qualitative study (Chapter 6) confirmed their positive attitudes towards the importance of nutrition for the health of the mother and baby, and their perceptions of the provision of nutrition advice as being an integral part of their professional role. However, the findings of the study indicate that there are other barriers that might exhibit greater effect on midwives’ practice in this area such as, model of care, lack of time, lack of education and resources. Midwives were also aware of the professional boundaries of their role in providing nutrition advice. They perceived that they need to provide general nutrition advice as they are not the experts. Perhaps, nutrition educational interventions directed to midwives need to put into consideration midwives’ models of care and their perceptions of their role. Development of tools to help midwives, in fragmented models of care with limited time, assess women’s diets and deliver brief and effective nutrition advice is needed. An example is the use of a quick screening tool to assess women’s diets and identify at risk groups that would benefit from dietitian referral (Langstroth et al. 2011). A recent study by Warren and colleagues (2016) has examined the feasibility and acceptability of a brief midwife led intervention (using motivational interviewing) to facilitate healthy eating and physical activity behaviours in pregnant women and found the intervention to be well received by pre-

159 gnant women who reported positive influences of the intervention on their dietary and physical activity behaviours. However, the feasibility and acceptability of the intervention for midwives were not assessed.

There was an attempt to investigate the association between the midwives’ mean score of nutrition knowledge and whether they provide nutrition advice or not. Midwives’ mean score of nutrition knowledge was significantly associated with the provision of nutrition advice (M = 13.76, SD = 2.01 versus M = 12.13, SD = 1.82, P = 0.000). Despite this significant association, the effect of the provision of nutrition advice on variance in the score of nutrition knowledge could not be determined. The majority of the midwives in this study indicated they provided nutrition advice (93%, n = 306), so the results were skewed. The midwives participating in the survey might have overestimated their practice in terms of the provision of nutrition advice. The data from the midwives’ qualitative study (Chapter 6) revealed that some of the midwives took a passive approach towards providing nutrition information to pregnant women, and some considered the mere provision of brochures (especially to seemingly healthy and motivated women) as adequate nutrition advice. Future studies are needed to confirm the relationship between midwives’ nutrition knowledge and their practice.

There was a significant association between midwives’ knowledge and their reception of nutrition education during midwifery education, and between midwives’ nutrition knowledge and their confidence in providing general nutrition advice. Professional nutrition education and confidence in providing general nutrition advice alongside other factors (principal place of practice and level of maternity services) had significant association with midwives’ nutrition knowledge although they only accounted for 7% of the variance in midwives’ nutrition knowledge. One explanation could be that there might be other factors affecting midwives’ knowledge that were not investigated in this study. Future research needs to investigate this area in greater details.

Overall, the conceptual framework of this study was successful in assuming the inadequacy of the KAB model alone to explain midwives’ behaviour of providing nutrition advice, and in incorporating a broad range of other factors such as professional nutrition education, confidence, role perceptions, model of care, and barriers and facilitators that are also related to midwives’ behaviour of providing nutrition advice. The risk of omitting factors affecting the behaviour was minimised. The framework, however; provided a better theoretical understanding of how these factors are affecting midwives’ behaviour of providing prenatal

160 nutrition advice rather than definitive answers, especially as some of the factors were only explored in a qualitative manner. More research is needed to confirm the factors investigated quantitatively (e.g., factors affecting knowledge and variance in knowledge and the relationship between knowledge and practice). A quantitative investigation is also needed to explore the relationship between midwives’ provision of nutrition advice and factors such as role perceptions and barriers.

Previous literature in the area of midwives and prenatal nutrition has not provided a theoretical framework. Midwives’ behaviour of nutrition advice is multifactorial. No single factor or a set of factors can adequately explain individual behaviours (Glanz and Bishop 2010). Personal factors and environmental and structural factors are both important. A broad understanding of the factors influencing midwives’ practices in providing nutrition education can provide the basis for well-designed interventions that can influence midwives’ behaviours in this area. The conceptual framework of this study emphasised that effective interventions directed to influencing midwives’ behaviour should not only target personal factors (e.g., knowledge, attitudes, confidence, and role perceptions) but also structural and environmental factors (professional nutrition education, model of care, and barriers and facilitators) (Glanz and Bishop 2010).

Some findings from this thesis may be appropriate to guide interventions based on the Theoretical Domains Framework (TDF). The TDF is a framework that was developed from a combination of psychological theories by a consensus approach among experts including: health psychology theorists, health service researchers, and health psychologists, as a means to make the application of theoretical approaches to interventions aiming at behaviour change, particularly in health care easy (Michie et al. 2005). The framework comprises 12 domains including: knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals, memory, attention and decision processes, environmental context and resources (environmental constraints), social influences, emotion, and behavioural regulation (Michie et al. 2005). Key areas from the TDF that could be targeted in interventions based on the findings of this thesis include: knowledge, beliefs about capabilities (self-efficacy), social/professional role and identity, social influences (norms), and environmental context and resources.

161 Knowledge gaps identified in this thesis that could be targeted in intervention studies include: weight gain recommendations, knowledge of supplements (e.g., iodine requirements) and knowledge of Australian dietary guidelines (e.g., dairy serves).

In the domain of beliefs about capabilities (self-efficacy), midwives in this study had moderate to low levels of confidence in providing general and specific nutrition-related advice but areas that might need specific attention in terms of increasing the level of confidence include: ‘weight gain and obesity’, ‘providing advice on vitamins’, discussing vegetarian diets, vegan diets, diets of women with previous or complex medical conditions, and diets of women from ethnic or minority groups.

In the domain of social/professional role and identity, as illustrated above, midwives’ perceptions of their role, and boundaries in providing nutrition advice need to be taken into considerations.

In the domain of social influences (norms), team-based approach was recognised by the midwives. Midwives considered the involvement of dietitians as the experts of nutrition to be important in educating them and pregnant women as well.

Finally in the environmental context and resources, several barriers/facilitators were identified by this thesis that affect midwives’ behaviour in the provision of nutrition advice and need to be targeted or considered in future interventions such as lack of time, lack of professional nutrition education and lack of resources.

8.7 Conclusions, recommendations, and future research

8.7.1 Conclusions

This thesis explored the role of Australian midwives in providing nutrition education during pregnancy, their knowledge, and education. It specifically investigated: midwives’ knowledge, attitudes, and confidence in providing nutrition advice. It also investigated the nutrition education the midwives received during midwifery education and during practice as well as midwives’ perceptions’ of their role and the barriers and facilitators related to it; and finally the thesis explored the nutrition content within midwifery education.

Midwives had inadequate levels of nutrition knowledge and variable levels of confidence, probably due to receiving limited nutrition education before or after being registered as a midwife. The received education was limited especially in terms of contemporary important

162 issues. Due to this lack of formal education in nutrition, midwives relied more on personal initiatives to seek continuing nutrition education. Despite perceiving their role in providing nutrition education as an integral part of their practice, this role was perceived to be restricted by many barriers. Nutrition was included in all midwifery programmes but the number of hours allocated was low and the education tended to be problem-oriented and based on various assumptions. There was also a lack of practical training for students in the provision of nutrition advice.

The findings of this thesis indicate missed opportunities for supporting the health of the mother and the baby during the antenatal period which represents a critical window of opportunity to intervene. The health care providers most in contact with pregnant women, namely the midwives, lack the necessary prerequisites to provide such support. There is room for improvement. The following recommendations are based on the implications of the research for practice and midwifery education so that midwives are able to be better supported in their role of providing nutrition support to pregnant women during the antenatal period.

8.7.2 Recommendations

Both the practising midwives and the programme coordinators provided insightful suggestions on issues that need to be addressed and initiatives that could assist to improve the efficacy of midwifery practice in supporting pregnant women to improve their nutrition.

Recommendation 1: Provision of continuing education in nutrition and dietary change.

It was clear from the results that in order to help practising midwives provide better nutrition advice and support, continuing education is essential, especially for midwives in public and rural hospitals. Continuing education needs to be provided by reliable and trusted sources, such as the ACM and midwives’ workplaces, to reduce midwives over reliance on personal initiatives and improve midwives access to the latest evidence-based updates in term of nutrition. The education needs to be focused on general as well as specific nutrition topics. This would provide equal opportunity for midwives who would like to improve or update general knowledge and the midwives who would like to target specific and challenging areas to do so.

Recommendation 2: Involvement of food and nutrition expertise in antenatal care settings.

163 More involvement of dietitians in antenatal care settings is recommended to provide resources and education for both pregnant women and the midwives. Positions for dietitians in antenatal care settings would address the current limited referral availability for hospital dietitians for issues other than gestational diabetes and obesity. More involvement of nutritionists in antenatal care community settings is also warranted..

Recommendation 3: Inclusion of specified nutrition knowledge and skills as core competency areas in Australian midwifery competency standards.

In terms of midwifery education, there is a need for minimum requirements of nutrition in Australian midwifery education and the inclusion of nutrition knowledge and skills as core competency areas in Australian midwifery competency standards. These competency areas would be best developed through consultation and collaboration between nutrition experts, midwifery educators, professional midwifery bodies such as the ANMAC, and include practising midwives and pregnant mothers.

Recommendations 4: Involvement of food and nutrition experts in the development and provision of nutrition curricula in midwifery education.

Nutrition education needs a team-based approach. This will ensure the quality of the education provided. Nutrition experts could develop online nutrition models to be used by all Australian midwifery programmes.

Recommendations 5: Inclusion of skills of nutrition assessment in midwifery nutrition curricula and the provision of opportunities for practical training for midwifery students.

In this way, the students would not only have theoretical nutrition knowledge but also the practical abilities that would enable them to assess pregnant women nutrition status and provide them with appropriate nutrition advice as the clinical antenatal guidelines recommend. This would ultimately make the midwifery students more prepared to practice after graduation and more proactive in providing nutrition advice to pregnant women and helping them improve their health and that of their babies’ and families’.

8.7.3 Future research

Future research needs to investigate midwives’ comprehensive knowledge of the Australian dietary guidelines and adherence to the antenatal clinical guidelines using validated surveys.

164 Research involving newly graduated midwives to investigate their knowledge and perceptions of received nutrition education during midwifery education is also recommended.

This research did not undertake actual observations of midwifery practice. This could be explored further in the future for more accurate account of midwives’ provision of nutrition advice.

Similar research can be conducted with other antenatal health care providers such as general practitioners and obstetricians to investigate their nutrition knowledge, attitudes, practices, and confidence in providing nutrition advice to pregnant women. Investigating nutrition education provided to those practitioners during basic education and during practice will be also of benefit.

There is also a need for on-going monitoring of education and of practice to ensure they are in line with the up to date evidence. Finally more research to investigate the best strategies to help midwives incorporate nutrition advice more effectively in their practice is needed as well as best strategies for better integration of nutrition into midwifery education.

165 REFERENCES

Adams, K. M., Butsch, W. S. and Kohlmeier, M. (2015) "The state of nutrition education at US medical schools." Journal of Biomedical Education. 15:357627, p. 7. DOI: 10.1155/2015/357627.

Adams, K. M., Kohlmeier, M., Powell, M. and Zeisel, S. H. (2010a). "Nutrition in medicine: Nutrition education for medical students and residents." Nutrition in Clinical Practice. 25(5): pp. 471–480.

Adams, K. M., Kohlmeier, M. and Zeisel, S. H. (2010b). "Nutrition education in US medical schools: Latest update of a national survey." Academic Medicine: Journal of the Association of American Medical Colleges. 85(9): pp. 1537–1542.

Adams, K. M., Lindell, K. C., Kohlmeier, M. and Zeisel, S. H. (2006). "Status of nutrition education in medical schools." The American Journal of Clinical Nutrition. 83(4): pp. 941S– 944S.

Arrish, J., Yeatman, H. and Williamson, M. (2014). "Midwives and nutrition education during pregnancy: A literature review." Women and Birth. 27(1): pp. 2–8.

Arrish, J., Yeatman, H. and Williamson, M. (2016a). "Australian midwives and provision of nutrition education during pregnancy: A cross sectional survey of nutrition knowledge, attitudes, and confidence." Women and Birth. 29(5): pp. 455–464.

Arrish, J., Yeatman, H. and Williamson, M. (2016b) "Nutrition education in Australian midwifery programmes: A mixed-methods study." Journal of Biomedical Education. 16:9680430, p. 12. DOI: 10.1155/2016/9680430.

Australian Bureau of Statistics. (2013). "Gender indicators, Australia." Retrieved November 5, 2014, from http://www.abs.gov.au/ausstats/[email protected]/Lookup/4125.0main+features3330Jan%202013

Australian College of Midwives. (2004). "Philosophy for midwifery." Retrieved September 7, 2015, from https://www.midwives.org.au/midwifery-philosophy

Australian College of Midwives. (2017). "About Us, An organisation for the midwifery profession." Retrieved March 20, 2017, from https://www.midwives.org.au/about- us

Australian Government Department of Health. (2013). "Review of Australian Government Health Workforce Programs, Nursing and midwifery education." Retrieved March 20, 2017, from http://www.health.gov.au/internet/publications/publishing.nsf/Content/work-review- australian-government-health-workforce-programs-toc~chapter-7-nursing-midwifery- workforce%E2%80%93education-retention-sustainability~chapter-7-nursing-midwifery- education

166 Australian Government National Preventive Health Taskforce (2008). Australia: The healthiest country by 2020. A discussion paper, Canberra. Australian Government. National Preventive Health Taskforce. Commonwealth of Australia. http://www.health.gov.au/internet/preventativehealth/publishing.nsf/content/a06c2fcf439ecda 1ca2574dd0081e40c/$file/discussion-28oct.pdf

Australian Health Minister's Conference (2011). National maternity services plan 2010, Canberra. Commonwealth of Australia. http://www.health.gov.au/internet/main/publishing.nsf/content/maternityservicesplan

Australian Health Ministers’ Advisory Council (2008). Primary maternity services in Australia: A framework for implementation, Canberra. Australian Health Ministers' Advisory Council.

Australian Health Ministers’ Advisory Council (2012). Clinical Practice Guidelines: Antenatal Care – Module 1, Canberra. Australian Government Department of Health and Aging. http://www.health.gov.au/antenatal

Australian Health Ministers’ Advisory Council (2014). Clinical Practice Guidelines: Antenatal Care – Module 2, Canberra. Australian Government Department of Health and Aging. http://www.health.gov.au/antenatal

Australian Institute of Health and Welfare (2013). Nursing and midwifery workforce 2012, Canberra. Australian Inistitute of Health and Welfare. National Health Workforce Series no. 6. Cat. no. HWL 52. https://www.aihw.gov.au/getmedia/39a135a3-9d8b-463b- a411-76ed5eb4a6b9/15994.pdf.aspx?inline=true

Australian Nursing and Midwifery Accreditation Council (2014). Midwife Accreditation Standards 2014, Canberra. Australian Nursing and Midwifery Accreditation Council, https:// www.anmac.org.au/sites/default/files/documents/ ANMAC_Midwife_Accreditation_Standards_2014.pdf

Australian Nursing and Midwifery Council (2006). National Competency Standards for the Midwife, Canberra. Australian Nursing and Midwifery Council, file:///C:/Users/Owner/ Downloads/Midwifery-Competency-Standards-January-2006%20(4).PDF

Australian Nursing and Midwifery Council (2009). Standards and criteria for the accreditation of nursing and midwifery courses leading to registration, enrolment, endorsement and authorisation in Australia—with evidence guide, Canberra. Australian Nursing and Midwifery Council, file:///C:/Users/Owner/Downloads/Midwives-- Accreditation-Standards.PDF

167 Baghianimoghadam, M. H., Ardakani, M. F., Akhoundi, M., Mortazavizadeh, M. R., Fallahzadeh, M. H. and Baghianimoghadam, B. (2012). "Effect of education on knowledge, attitude and behavioral intention in family relative with colorectal cancer patients based on theory of planned behavior." Asian Pacific Journal of Cancer Prevention. 13(12): pp. 5995-5998.

Baker, P. N., Wheeler, S. J., Sanders, T. A., Thomas, J. E., Hutchinson, C. J., Clarke, K., Berry, J. L., Jones, R. L., Seed, P. T. and Poston, L. (2009). "A prospective study of micronutrient status in adolescent pregnancy." The American Journal of Clinical Nutrition. 89(4): pp. 1114–1124.

Bandura, A. (1977). "Self-efficacy: Towards a unifying theory of behaviour change." Psychology Review. 84: pp. 191–215.

Baranowski, T., Cullen, K. W., Nicklas, T., Thompson, D. and Baranowski, J. (2003). "Are current health behavioral change models helpful in guiding prevention of weight gain efforts?" Obesity research. 11(S10): pp. 23S–43S.

Barker, D. J., Gluckman, P. D., Godfrey, K. M., Harding, J. E., Owens, J. A. and Robinson, J. S. (1993a). "Fetal nutrition and in adult life." Lancet. 341(8850): pp. 938– 941.

Barker, D. J., Winter, P. D., Osmond, C., Margetts, B. and Simmonds, S. J. (1989). "Weight in infancy and death from ischaemic heart disease." Lancet. 2(8663): pp. 577–580.

Barker, D. J. P., Hales, C. N., Fall, C. H. D., Osmond, C., Phipps, K. and Clark, P. M. S. (1993b). "Type 2 (non-insulin-dependent) diabetes mellitus, hypertension and hyperlipidaemia (syndrome X): Relation to reduced fetal growth." Diabetologia. 36(1): pp. 62–67.

Barrowclough, D. and Ford, f. (2001). "A nutrition open-learning pack for practising midwives." Nutrition and Food Science. 31(1): pp. 6–12.

Basu, A., Kennedy, L., Tocque, K. and Jones, S. (2014) "Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy." BMC Pregnancy and . 14:218, p. 11. DOI: 10.1186/1471-2393-14-218.

Begley, A. (2002). "Barriers to good nutrient intakes during pregnancy: A qualitative analysis." Nutrition and Dietetics 59(3): pp. 175–180.

168 Beldon, A. and Crozier, S. (2005). "Health promotion in pregnancy: The role of the midwife." The Journal of the Royal Society for the Promotion of Health. 125(5): pp. 216–220.

Better Health Channel. (2014). "Pregnancy and diet." Retrieved 14 Octobor, 2016, from https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-and-diet.

Bettinghaus, E. P. (1986). "Health promotion and the knowledge-attitude- behavior continuum." Preventive Medicine. 15(5): pp. 475–491.

Biro, M. A. (2011). "What has public health got to do with midwifery? Midwives’ role in securing better health outcomes for mothers and babies." Women and Birth. 24(1): pp. 17–23.

Biro, M. A., Cant, R., Hall, H., Bailey, C., Sinni, S. and East, C. (2013). "How effectively do midwives manage the care of obese pregnant women? A cross-sectional survey of Australian midwives." Women and Birth. 26(2): pp. 119–124.

Blumfield, M., Hure, A., MacDonald-Wicks, L., Patterson, A., Smith, R. and Collins, C. (2011) "Disparities exist between National food group recommendations and the dietary intakes of women." BMC Women's Health. 11:37, p. 9. DOI: 10.1186/1472-6874-11-37.

Bondarianzadeh, D., Yeatman, H. and Condon-Paoloni, D. (2007). "Listeria education in pregnancy: Lost opportunity for health professionals." Australian and New Zealand Journal of Public Health. 31(5): pp. 468–474.

Bondarianzadeh, D., Yeatman, H. and Condon-Paoloni, D. (2011). "A qualitative study of the Australian midwives’ approaches to Listeria education as a food-related risk during pregnancy." Midwifery. 27(2): pp. 221–228.

Bookari, K., Yeatman, H. and Williamson, M. (2016a) "Australian pregnant women's awareness of gestational weight gain and dietary guidelines: Opportunity for action." Journal of Pregnancy. 16: 8162645, p. 9. DOI: 10.1155/2016/8162645.

Bookari, K., Yeatman, H. and Williamson, M. (2016b) "Exploring Australian women’s level of nutrition knowledge during pregnancy: A cross-sectional study." International Journal of Women's Health. 16:8, pp. 405–419. DOI: 10.2147/IJWH.S110072.

Bookari, K., Yeatman, H. and Williamson, M. (2017). "Falling short of dietary guidelines – What do Australian pregnant women really know? A cross sectional study." Women and Birth. 30(1): pp. 9–17.

Brantsæter, A. L., Haugen, M., Myhre, R., Sengpiel, V., Englund-Ögge, L., Miodini Nilsen, R., Borgen, I., Duarte-Salles, T., Papadopoulou, E., Vejrup, K., von Ruesten, A., Rudjord Hillesund, E., Birgisdottir, B. E., Lill Trogstad, P. M., Jacobsson, B., Bacelis, J., Myking, S., Knutsen, H. K., Kvalem, H. E. and Alexander, J. (2014). "Diet matters, particularly in pregnancy - Results from MoBa studies of maternal diet and pregnancy outcomes." Norsk Epidemiologi. 24(1/2): pp. 63–77. 169 Braun, V. and Clarke, V. (2006). "Using thematic analysis in psychology." Qualitative Research in Psychology. 3(2): pp. 77–101.

Butler, K., Yeatman, H. and Condon-Paloni, D. (2008). Review of antenatal clinic education materials in NSW hospitals Wollongong. University of Wollongong.

Calkins, K. and Devaskar, S. U. (2011). "Fetal origins of adult disease." Current Problems in Pediatric and Adolescent Health Care. 41(6): pp. 158–176.

Cantrill, R. M., Creedy, D. K. and Cook, M. (2003). "An Australian study of midwives' breast-feeding knowledge." Midwifery. 19(4): pp. 310–317.

Chang, L., Popovich, N. G., Iramaneerat, C., Smith Jr, E. V. and Lutfiyya, M. N. (2008). "A clinical nutrition course to improve pharmacy students' skills and confidence in counseling patients." American Journal of Pharmaceutical Education. 72(3): p. 66.

Chang, T., Llanes, M., Gold, K. J. and Fetters, M. D. (2013) "Perspectives about and approaches to weight gain in pregnancy: A qualitative study of physicians and nurse midwives." BMC Pregnancy and Childbirth. 13:47, p. 7. DOI: 10.1186/1471-2393-13-47.

Cheyne, M. and Moreno-Black, G. (2010). "Nutritional counseling in midwifery and obstetric practice." Ecology of Food and Nutrition. 49(1): pp. 1–29.

Cogswell, M. E., Scanlon, K. S., Fein, S. B. and Schieve, L. A. (1999). "Medically advised, mother's personal target, and actual weight gain during pregnancy." and Gynecology 94(4): pp. 616–622.

Creswell, J. W. (2009). Research design: Qualitative and mixed methods approaches. Thousand Oaks, California, SAGE Publications. 3rd ed.

Creswell, J. W. and Clark, V. L. P. (2007). Designing and conducting mixed methods research. Thousand Oaks, California, SAGE Publications.

Creswell, J. W. and Clark, V. L. P. (2011). Designing and conducting mixed methods research. Thousand Oaks, California, SAGE Publications. 2nd ed.

Creswell, J. W., Klassen, A. C., Plano Clark, V. L. and Smith, K. C. (2011). Best practices for mixed methods research in the health sciences. Bethesda, MD: National Institutes of Health.

Davies, P. S., Funder, J., Palmer, D. J., Sinn, J., Vickers, M. H. and Wall, C. R. (2016). "Early life nutrition and the opportunity to influence long-term health: An Australasian perspective." Journal of Developmental Origins of Health and Disease. 7(5): pp. 440–448.

170 Davis, D. L., Raymond, J. E., Clements, V., Adams, C., Mollart, L. J., Teate, A. J. and Foureur, M. J. (2012). "Addressing obesity in pregnancy: The design and feasibility of an innovative intervention in NSW, Australia." Women and Birth. 25(4): pp. 174–180.

de Jersey, S., Nicholson, J., Callaway, L. and Daniels, L. (2013) "An observational study of nutrition and physical activity behaviours, knowledge, and advice in pregnancy." BMC Pregnancy and Childbirth. 13:115, p. 8 DOI: 10.1186/1471-2393-13-115.

Dietitians Association of Australia. (2017). "Information for Healtcare Professionals" Retrieved October 11, 2017, from https://daa.asn.au/what-dietitans-do/ information-for-healthcare-professionals/

Dimaria-Ghalili, R. A., Edwards, M., Friedman, G., Jaferi, A., Kohlmeier, M., Kris-Etherton, P., Lenders, C., Palmer, C. and Wylie-Rosett, J. (2013). "Capacity building in nutrition science: revisiting the curricula for medical professionals." Annals of the New York Academy of Sciences. 1306(1): pp. 21–40.

Dodd, J. M., Cramp, C., Sui, Z., Yelland, L. N., Deussen, A. R., Grivell, R. M., Moran, L. J., Crowther, C. A., Turnbull, D. and McPhee, A. J. (2014) "The effects of antenatal dietary and lifestyle advice for women who are overweight or obese on maternal diet and physical activity: The LIMIT randomised trial." BMC Medicine. 12:161, p. 19. DOI: 10.1186/s12916- 014-0161-y.

Elias, S. and Green, T. (2007). "Nutrition knowledge and attitudes of New Zealand registered midwives." Nutrition and Dietetics. 64(4): pp. 290–294.

Elias, S. and Stewart, S. (2005). "Developing nutrition within the midwifery curriculum." British Journal of Midwifery. 13(7): pp. 456–460.

Elo, S. and Kyngas, H. (2008). "The qualitative content analysis process." Journal of Advanced Nursing. 62(1): pp. 107–115.

Etikan, I., Musa, S. A. and Alkassim, R. S. (2016) "Comparison of convenience sampling and purposive sampling." American Journal of Theoretical and Applied Statistics. 5:1, pp. 1-4. DOI: 10.11648/j.ajtas.20160501.11.

Everette, M. (2009). "A Review of nutrition education: Before, between and beyond pregnancy." Current Women and Health Reviews. 5(4): pp. 193–200.

Farrar, D. (2013). "Nutrition advice in pregnancy." The Practising Midwife. 16(9): pp. 13–17.

Fowles, E. R. and Fowles, S. L. (2008). "Healthy eating during pregnancy: Determinants and supportive strategies." Journal of Community Health Nursing. 25(3): pp. 138–152.

Frenk, J., Chen, L., Bhutta, Z., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S.,

171 Scrimshaw, S., Sepulveda, J., Serwadda, D. and Zurayk, H. (2010). "Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world." The Lancet (British edition). 376(9756): pp. 1923–1958.

Furber, C. M. and Thomson, A. M. (2008). "The emotions of integrating breastfeeding knowledge into practice for English midwives: A qualitative study." International Journal of Nursing Studies. 45(2): pp. 286–297.

Furness, P. J., Arden, M. A., Duxbury, A. M., Hampshaw, S. M., Wardle, C. and Soltani, H. (2014) "Talking about weight in pregnancy: An exploration of practitioners' and women's perceptions." Journal of Nursing Education and Practice. 5:2, pp. 89-102. DOI: 10.5430/jnep.v5n2p89.

Garg, A. and Kashyap, S. (2006). "Effect of counseling on nutritional status during pregnancy." Indian Journal of Pediatrics. 73(8): pp. 687–692.

Garnweidner, L. M., Sverre Pettersen, K. and Mosdol, A. (2013). "Experiences with nutrition-related information during antenatal care of pregnant women of different ethnic backgrounds residing in the area of Oslo, Norway." Midwifery. 29(12): pp. e130-137.

Glanz, K. and Bishop, D. B. (2010) "The role of behavioral science theory in development and implementation of public health interventions." Annual Review of Public Health. 31:1, pp. 399-418. DOI: 10.1146/annurev.publhealth.012809.103604.

Graneheim, U. H. and Lundman, B. (2004). "Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness." Nurse Education Today. 24(2): pp. 105–112.

Grimes, H. A., Forster, D. A. and Newton, M. S. (2014). "Sources of information used by women during pregnancy to meet their information needs." Midwifery. 30(1): pp. e26-e33.

Grol, R. and Wensing, M. (2004). "What drives change? Barriers to incentives for achieving evidence-based practice." BMJ.180 (6 Suppl): pp. s57–s60.

Guelinckx, I., Devlieger, R., Beckers, K. and Vansant, G. (2008). "Maternal obesity: Pregnancy complications, gestational weight gain and nutrition." Obesity Reviews. 9(2): pp. 140–150.

Guest, G., Bunce, A. and Johnson, L. (2006). "How many iInterviews are enough? An experiment with data saturation and variability." Field Methods. 18(1): pp. 59–82.

Harding, J. (2001). "The nutritional basis of the fetal origins of adult disease." International Journal of . 30(1): pp. 15–23.

172 Hatem, M., Sandall, J., Devane, D., Soltani, H. and Gates, S. (2008) "Midwife-led versus other models of care for childbearing women." The Cochrane database of systematic reviews.8:4, p. 109. DOI: 10.1002/14651858.CD004667.pub2.

Heslehurst, N., Crowe, L., Robalino, S., Sniehotta, F., McColl, E. and Rankin, J. (2014) "Interventions to change maternity healthcare professionals' behaviours to promote weight- related support for obese pregnant women: A systematic review." Implementation Science. 9:97, p. 5. DOI: 10.1186/s13012-014-0097-9.

Heslehurst, N., Russell, S., McCormack, S., Sedgewick, G., Bell, R. and Rankin, J. (2013). "Midwives perspectives of their training and education requirements in maternal obesity: A qualitative study." Midwifery. 29(7): pp. 736–744.

Higginbottom, G. M., Vallianatos, H., Forgeron, J., Gibbons, D., Mamede, F. and Barolia, R. (2014) "Food choices and practices during pregnancy of immigrant women with high-risk pregnancies in Canada: A pilot study." BMC Pregnancy and Childbirth. 14:370, p. 13. DOI: 10.1186/s12884-014-0370-6.

Hillenbrand, K. M. and Larsen, P. G. (2002). "Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians." Pediatrics. 110(5): pp. e59-e59.

Hillesund, E. R., Bere, E., Haugen, M. and Øverby, N. C. (2014). "Development of a New Nordic Diet score and its association with gestational weight gain and fetal growth – A study performed in the Norwegian Mother and Child Cohort Study (MoBa)." Public Health Nutrition. 17(9): pp. 1909–1918.

Homer, C., Ellwood, D., Kildea, S., Brodie, P., Curtin, A. and Griffiths, M. (2010). Core competencies and educational framework for maternity services in Australia project. Sydney: University of Technology.

Hughes, R., Maher, J., Baillie, E. and Shelton, D. (2011). "Nutrition and physical activity guidance for women in the pre- and post-natal period: A continuing education needs assessment in primary health care." Australian Journal of Primary Health. 17(2): pp. 135– 141.

Hure, A., Young, A., Smith, R. and Collins, C. (2009). "Diet and pregnancy status in Australian women." Public Health Nutrition. 12(06): pp. 853–861.

Hynes, K. L., Otahal, P., Hay, I. and Burgess, J. R. (2013). "Mild iodine deficiency during pregnancy is associated with reduced educational outcomes in the offspring: 9-year follow-up of the gestational iodine cohort." The Journal of Clinical Endocrinology and Metabolism 98(5): pp. 1954–1962.

International Confederation of Midwives (2010). Essential competencies for basic midwifery practice. International Confederation of Midwives. http://internationalmidwives.org/assets/ uploads/documents/CoreDocuments/ICM%20Essential%20Competencies%20for%20Basic% 20Midwifery%20Practice%202010,%20revised%202013.pdf 173 Johanson, R., Newburn, M. and Macfarlane, A. (2002). "Has the medicalisation of childbirth gone too far?" BMJ : British Medical Journal. 324(7342): pp. 892–895.

Johnson, R. B. and Onwuegbuzie, A. J. (2004). "Mixed methods research: A research paradigm whose time has come." Educational Researcher. 33(7): pp. 14–26.

Jones, G., Riley, M. and Dwyer, T. (2000). "Maternal diet during pregnancy is associated with bone mineral density in children: A longitudinal study " European Journal of Clinical Nutrition 54: pp. 749–756.

Jones, S. C., Telenta, J., Shorten, A. and Johnson, K. (2011). "Midwives and pregnant women talk about alcohol: What advice do we give and what do they receive?" Midwifery. 27(4): pp. 489–496.

Knowles, M. (1975). Self-Directed Learning: A guide for learners and teachers. New York NY, Associated Press.

Kolasa, K. M., Zinn, B. and Moss, N. (1997). "Nutrition education of nurse-midwives: One example." Topics in Clinical Nutrition. 12(3): pp. 58–62.

Kris-Etherton, P. M., Akabas, S. R., Bales, C. W., Bistrian, B., Braun, L., Edwards, M. S., Laur, C., Lenders, C. M., Levy, M. D., Palmer, C. A., Pratt, C. A., Ray, S., Rock, C. L., Saltzman, E., Seidner, D. L. and Van Horn, L. (2014). "The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness." American Journal of Clinical Nutrition. 99(5 Suppl): pp. 1153S–1166S.

Kris-Etherton, P. M., Akabas, S. R., Douglas, P., Kohlmeier, M., Laur, C., Lenders, C. M., Levy, M. D., Nowson, C., Ray, S. and Pratt, C. A. (2015). "Nutrition Competencies in Health Professionals’ Education and Training: A New Paradigm." Advances in Nutrition: An International Review Journal. 6(1): pp. 83–87.

Langford, A., Joshu, C., Chang, J. J., Myles, T. and Leet, T. (2011). "Does gestational weight gain affect the risk of adverse maternal and infant outcomes in overweight women?" Maternal and Child Health Journal. 15(7): pp. 860–865.

Langstroth, C., Wright, C. and Parkington, T. (2011). "Implementation and evaluation of a nutritional screening tool." British Journal of Midwifery. 19(1): pp. 15-21.

Leach, L. (2011). "Placental vascular dysfunction in diabetic pregnancies: Intimations of fetal cardiovascular disease?" Microcirculation. 18(4): pp. 263–269.

174 Lee, A., Belski, R., Radcliffe, J. and Newton, M. (2016). "What do pregnant women know about the healthy eating guidelines for pregnancy? A web-based questionnaire." Maternal and Child Health Journal. 20(10): pp. 2179–2188.

Lee, D., Haynes, C. and Garrod, D. ( 2010). Exploring health promotion practice within maternity services: Final Report., London. NHS Foundation Trust.

Lee, D. J., Haynes, C. L. and Garrod, D. (2012). "Exploring the midwife's role in health promotion practice." British Journal of Midwifery. 20(3): pp. 178–186.

Leece, P., Bhandari, M., Sprague, S., Swiontkowski, M. F., Schemitsch, E. H., Tornetta, P., Devereaux, P. J. and Guyatt, G. H. (2004) "Internet versus mailed questionnaires: A randomized comparison (2)." Journal of medical Internet research. 6:3, p. e30. DOI: 10.2196/jmir.6.3.e29.

Lucas, C., Charlton, K. and Yeatman, H. (2014a). "Nutrition advice during pregnancy: Do women receive it and can health professionals provide it?" Maternal and Child Health Journal. 18(10): pp. 2465–2478.

Lucas, C. J., Charlton, K. E., Brown, L., Brock, E. and Cummins, L. (2014b). "Antenatal shared care: Are pregnant women being adequately informed about iodine and nutritional supplementation?" Australian and New Zealand Journal of Obstetrics and Gynaecology. 54(6): pp. 515–521.

Macleod, M., Gregor, A., Barnett, C., Magee, E., Thompson, J. and Anderson, A. S. (2013). "Provision of weight management advice for obese women during pregnancy: A survey of current practice and midwives' views on future approaches." Maternal and Child Nutrition 9(4): pp. 467-472.

Malek, L., Umberger, W., Makrides, M. and Zhou, S. J. (2016). "Adherence to the Australian dietary guidelines during pregnancy: Evidence from a national study." Public Health Nutrition. 19(7): pp. 1155–1163.

Marchi, J., Berg, M., Dencker, A., Olander, E. K. and Begley, C. (2015). "Risks associated with obesity in pregnancy, for the mother and baby: A systematic review of reviews." Obesity Reviews 16(8): pp. 621–638.

Martin, J. C., Savige, G. S. and Mitchell, E. K. L. (2014). "Health knowledge and iodine intake in pregnancy." Australian and New Zealand Journal of Obstetrics and Gynaecology. 54(4): pp. 312–316.

Martyn, C. N. (1994). "Fetal and infant origins of cardiovascular disease." Midwifery. 10(2): pp. 61–66.

Maxwell, J. (2013). Qualitative research design: An interactive approach., Thousand Oaks, California, SAGE Publications. 3nd ed.

175 May, L., Suminski, R., Berry, A., Linklater, E. and Jahnke, S. (2014). "Diet and pregnancy: Health-care providers and patient behaviors." The Journal of Perinatal Education. 23(1): pp. 50–56.

McIntyre, H. D., Gibbons, K. S., Flenady, V. J. and Callaway, L. K. (2012). "Overweight and obesity in Australian mothers: Epidemic or endemic." Medical Journal of Australia. 196(3): pp. 184–188.

McMillen, I. C., MacLaughlin, S. M., Muhlhausler, B. S., Gentili, S., Duffield, J. L. and Morrison, J. L. (2008). "Developmental origins of adult health and disease: The role of periconceptional and foetal nutrition." Basic and Clinical Pharmacology and Toxicology. 102(2): pp. 82–89.

McNeill, J., Doran, J., Lynn, F., Anderson, G. and Alderdice, F. (2012) "Public health education for midwives and midwifery students: A mixed methods study." BMC Pregnancy and Childbirth. 12:142, p. 9. DOI: 10.1186/1471-2393-12-142.

Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D. and Walker, A. (2005) "Making psychological theory useful for implementing evidence based practice: A consensus approach." Quality and Safety in Health Care 14:1, pp. 26–33. DOI: doi: 10.1136/qshc.2004.011155.

Ministry of Health (2008). Food and nutrition guidelines for healthy pregnant women-A background paper., Wellington New Zealand. Ministry of Health. https://www.health.govt.nz/system/files/documents/publications/food-and-nutrition- guidelines-preg-and-bfeed.pdf

Ministry of Health (2015). Report on maternity, 2012, Wellington New Zealand. Ministry of Health. http://www.health.govt.nz/publication/report-maternity-2012

Muktabhant, B., Lawrie, T. A., Lumbiganon, P. and Laopaiboon, M. (2015) "Diet or exercise, or both, for preventing excessive weight gain in pregnancy." The Cochrane Database of Systematic Reviews 15:6, p. 260. DOI: 10.1002/14651858.CD007145.pub3.

Mulliner, C. M., Spiby, H. and Fraser, R. (1995). "A study exploring midwives' education in, knowledge of and attitudes to nutrition in pregnancy." Midwifery. 11(1): pp. 37–41.

Murad, M. H., Coto-Yglesias, F., Varkey, P., Prokop, L. J. and Murad, A. L. (2010). "The effectiveness of self-directed learning in health professions education: A systematic review." Medical Education Online. 44(11): pp. 1057-1068.

Murad, M. H. and Varkey, P. (2008). "Self-directed learning in health professions education." Annals of the Academy of Medicine, Singapore. 37(7): pp. 580-590.

National Health and Medical Research Council. (2010). "Iodine supplemntation for pregnanct and breastfeeding women." Retrieved May 4, 2012, from https://www.nhmrc.gov.au/guidelines-publications/new45

176 National Health and Medical Research Council. (2013). "Australian Dietary Guidelines." Retrieved February 20, 2015, from http://nhmrc.gov.au/guidelines-publications/n55

National Health and Research Council (2006). Nutrient reference values for Australians and NewZealand including recommended dietary intakes Canberra. National Health and Research Council. http://www.nhmrc.gov.au/guidelines-publications/n35-n36-n37

National Institute for Health and Clinical Excellence (2008). Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households, London, UK. National Institute for Health and Clinical Excellence. https://www.guidelinecentral.com/summaries/improving-the-nutrition-of-pregnant-and- breastfeeding-mothers-and-children-in-low-income-households/#section-date

Neergaard, M. A., Olesen, F., Andersen, R. S. and Sondergaard, J. (2009). "Qualitative description – The poor cousin of health research?" BMC Medical Research Methodology. 9: 52, p. 5. DOI: 10.1186/1471-2288-9-52.

O’Leary, Z. (2004). The Essential Guide to Doing Research. London, SAGE Publications.

Olander, E. K., Atkinson, L., Edmunds, J. K. and French, D. P. (2011). "The views of pre- and post-natal women and health professionals regarding gestational weight gain: An exploratory study." Sexual and Reproductive HealthCare 2(1): pp. 43–48.

Pan, S. Y. A., Dixon, L., Paterson, H. and Campbell, N. (2014). "New Zealand LMC midwives’ approaches to discussing nutrition, activity and weight gain during pregnancy." New Zealand College of Midwives Journal. 50(4): pp. 24–29.

Pasinlioglu, T. (2004). "Health education for pregnant women: The role of background characteristics." Patient Education and Counseling. 53(1): pp. 101–106.

Phelan, S. (2010). "Pregnancy: A “teachable moment” for weight control and obesity prevention." American Journal of Obstetrics and Gynecology. 202(2): pp. 135. e1–135. e8.

Porteous, H. E., Palmer, M. A. and Wilkinson, S. A. (2014). "Informing maternity service development by surveying new mothers about preferences for nutrition education during their pregnancy in an area of social disadvantage." Women and Birth. 27(3): pp. 196–201.

Puolakka, J., Janne, O., Pakarinen, A., Jarvinen, P. A. and Vihko, R. (1980). "Serum ferritin as a measure of iron stores during and after normal pregnancy with and without iron supplements." Acta Obstetrica Gynecologica Scandinavia Suppl. 95: pp. 43–51.

Raosoft. (2004). "Sample Size Calculator." Retrieved November 20, 2011, from http://www.raosoft.com/samplesize.html

Raymond, J. and Clements, V. (2013). "Motivational interviewing for midwives: Creating 'enabling' conversations with women." MIDIRS Midwifery Digest. 23(4): pp. 435–440.

177 Saravanan, P. and Yajnik, C. S. (2010). "Role of maternal vitamin B12 on the metabolic health of the offspring: A contributor to the diabetes epidemic?" The British Journal of Diabetes and Vascular Disease. 10(3): pp. 109–114.

Sarmugam, R., Worsley, A. and Flood, V. (2014). "Development and validation of a salt knowledge questionnaire." Public Health Nutrition. 17(5): pp. 1061–1068.

Schaller, C. and James, E. L. (2005). "The nutritional knowledge of Australian nurses." Nurse Education Today. 25(5): pp. 405–412.

Schmied, V. A., Duff, M., Dahlen, H. G., Mills, A. E. and Kolt, G. S. (2011). "‘Not waving but drowning’: A study of the experiences and concerns of midwives and other health professionals caring for obese childbearing women." Midwifery. 27(4): pp. 424–430.

Shub, A., Huning, E. Y., Campbell, K. J. and McCarthy, E. A. (2013) "Pregnant women’s knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy." BMC Research Notes. 6:278, p. 6. DOI: 10.1186/1756-0500-6-278.

Sinikovic, D., Yeatman, H., Cameron, D. and Meyer, B. (2008). "Women’s awareness of the importance of long-chain omega-3 polyunsaturated fatty acid consumption during pregnancy: Knowledge of risks, benefits and information accessibility." Public Health Nutrition. 12 (4): pp. 562–569.

State of Queensland Queensland Health (2015). Maternal and infant nutrition e- Learning platforms review. Children’s Health Queensland Hospital and Health Service.

Streuling, I., Beyerlein, A. and von Kries, R. (2010). "Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials." The American Journal of Clinical Nutrition. 92(4): pp. 678–687.

Swaminathan, B. and Gerner-Smidt, P. (2007). "The epidemiology of human listeriosis." Microbes and Infection. 9(10): pp. 1236–1243.

Symon, A. (2002). "Midwives' nutrition knowledge: An evaluation." The Practising Midwife. 5(10): pp. 24–25.

Szwajcer, E. M., Hiddink, G. J., Koelen, M. A. and van Woerkum, C. M. J. (2005). "Nutrition-related information-seeking behaviours before and throughout the course of pregnancy: Consequences for nutrition communication." European Journal of Clinical Nutrition. 59(S1): pp. S57–S65.

Szwajcer, E. M., Hiddink, G. J., Koelen, M. A. and van Woerkum, C. M. J. (2007). "Nutrition awareness and pregnancy: Implications for the life course perspective." European Journal of Obstetrics, Gynecology, and Reproductive biology. 135(1): pp. 58–64.

178 Szwajcer, E. M., Hiddink, G. J., Koelen, M. A. and van Woerkum, C. M. J. (2009). "Written nutrition communication in midwifery practice: What purpose does it serve?" Midwifery. 25(5): pp. 509–517.

Szwajcer, E. M., Hiddink, G. J., Maas, L., Koelen, M. A. and Van Woerkum, C. M. (2008). "Nutrition-related information-seeking behaviours of women trying to conceive and pregnant women: Evidence for the life course perspective." Family Practice. 25(S1): pp. i99– i104.

Thangaratinam, S. (2015). "Diet and lifestyle interventions for obese pregnant women." The Lancet Diabetes and Endocrinology. 3(10): pp. 748-749.

Thangaratinam, S., Rogozińska, E., Jolly, K., Glinkowski, S., Roseboom, T., Tomlinson, J. W., Kunz, R., Mol, B. W., Coomarasamy, A. and Khan, K. S. (2012). "Effects of interventions in pregnancy on maternal weight and obstetric outcomes: Meta-analysis of randomised evidence." British Medical Journal (Clinical Research Ed.). 344: p. e 2088. DOI: https://doi.org/10.1136/bmj.e2088.

The Royal Australian College of General Practitioners (2016). General practice management of : 2016–18, East Melbourne, Victoria. The Royal Australian College of General Practitioners. https://static.diabetesaustralia.com.au/s/fileassets/diabetes- australia/5d3298b2-abf3-487e-9d5e-0558566fc242.pdf

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2014). Standards of maternity care in Australia and New Zealand, East Melbourne Victoria. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical- Obstetrics/Standards-in-Maternity-Care-(C-Obs-41)-Review-March-2016.pdf?ext=.pdf

Thyrian, J. R., Hannöver, W., Röske, K., Scherbarth, S., Hapke, U. and John, U. (2006). "Midwives’ attitudes to counselling women about their smoking behaviour during pregnancy and postpartum." Midwifery. 22(1): pp. 32–39.

Touger-Decker, R., Benedict Barracato, J. M. and O'Sullivan-Maillet, J. (2001). "Nutrition education in health professions programs: A survey of dental, physician assistant, nurse practitioner, and nurse midwifery programs." Journal of the American Dietetic Association. 101(1): pp. 63–69.

Tovar, A., Must, A., Bermudez, O., Hyatt, R. and Chasan-Taber, L. (2009). "The impact of gestational weight gain and diet on abnormal glucose tolerance during pregnancy in Hispanic women." Maternal and Child Health Journal. 13(4): pp. 434–434.

Uusitalo, U., Arkkola, T., Ovaskainen, M.-L., Kronberg-Kippilä, C., Kenward, M. G., Veijola, R., Simell, O., Knip, M. and Virtanen, S. M. (2009). "Unhealthy dietary patterns are associated with weight gain during pregnancy among Finnish women." Public Health Nutrition. 12(12): pp. 2392–2399.

179 Waller, A., Bryant, J., Cameron, E., Galal, M., Quay, J. and Sanson-Fisher, R. (2016) "Women’s perceptions of antenatal care: Are we following guideline recommended care?" BMC Pregnancy and Childbirth. 16:191, p. 10. DOI: 10.1186/s12884-016-0984-y.

Warren, L., Rance, J. and Hunter, B. (2017) "Eat Well Keep Active: Qualitative findings from a feasibility and acceptability study of a brief midwife led intervention to facilitate healthful dietary and physical activity behaviours in pregnant women." Midwifery 49(2017): 117–123.

Wen, L., Flood, V., Simpson, J., Rissel, C. and Baur, L. (2010) "Dietary behaviours during pregnancy: Findings from first-time mothers in southwest Sydney, Australia." International Journal of Behavioral Nutrition and Physical Activity. 7:13, p. 7. DOI: 10.1186/1479-5868-7- 13.

Wennberg, A.-L., Hörnsten, Å. and Hamberg, K. (2015) "A questioned authority meets well- informed pregnant women–A qualitative study examining how midwives perceive their role in dietary counselling." BMC Pregnancy and Childbirth. 15:88, p. 10. DOI: 10.1186/s12884- 015-0523-2.

Wennberg, A. L., Hamberg, K. and Hörnsten, Å. (2014). "Midwives' strategies in challenging dietary and weight counselling situations." Sexual and Reproductive Healthcare. 5(3): pp. 107–112.

Wennberg, A. L., Lundqvist, A., Högberg, U., Sandström, H. and Hamberg, K. (2013). "Women's experiences of dietary advice and dietary changes during pregnancy." Midwifery. 29(9): pp. 1027–1034.

Wilkinson, S., Poad, D. and Stapleton, H. (2013) "Maternal overweight and obesity: A survey of clinicians' characteristics and attitudes, and their responses to their pregnant clients." BMC Pregnancy and Childbirth. 13:117, p. 8. DOI: 10.1186/1471-2393-13-117.

Wilkinson, S. A. and Stapleton, H. (2012). "Overweight and obesity in pregnancy: The evidence–practice gap in staff knowledge, attitudes and practices." Australian and New Zealand Journal of Obstetrics and Gynaecology. 52(6): pp. 588–592.

Wilkinson, S. A. and Tolcher, D. (2010). "Nutrition and maternal health: What women want and can we provide it?" Nutrition and Dietetics. 67(1): pp. 18–25.

Willcox, J., Campbell, K., van der Pligt, P., Hoban, E., Pidd, D. and Wilkinson, S. (2012). "Excess gestational weight gain: An exploration of midwives' views and practice." BMC Pregnancy and Childbirth. 12:102, p. 11. DOI: 10.1186/1471-2393-12-102.

Williamson, C., Lean, M. and Combet, E. (2012). Dietary iodine: awareness, knowledge and current practice among midwives. Proceedings of the Nutrition Society.

Williamson, C. S. (2006). "Nutrition in pregnancy." Nutrition Bulletin. 31(1): pp. 28–59.

180 Williamson, M. and Harrison, L. (2010). "Providing culturally appropriate care: A literature review." International Journal of Nursing Studies. 47(6): pp. 761–769.

Wills, G. and Forster, D. (2008). "Nausea and vomiting in pregnancy: What advice do midwives give?" Midwifery. 24(4): pp. 390–398.

Wise, N. J. and Arcamone, A. A. (2011). "Survey of adolescent views of healthy eating during pregnancy." MCN: The American Journal of Maternal/Child Nursing. 36(6): pp. 381–386.

World Medical Association. (2013). "WMA declaration of Helsinki: Ethical principles for medical research involving human subjects." Retrieved October 11, 2017, from https://www.wma.net/wp-content/uploads/2016/11/DoH-Oct2013-JAMA.pdf

World Health Organization (2016). "WHO recommendations on antenatal care for a positive pregnancy experience." World Health Organization, Geneva.

Yajnik, C. S. and Deshmukh, U. S. (2012). ": Maternal nutrition and role of one-carbon metabolism." Reviews in Endocrine and Metabolic Disorders 13(2): pp. 121–127.

Yetter, G. and Capaccioli, K. (2010). "Differences in responses to web and paper surveys among school professionals." Behavior Research Methods 42(1): pp. 266–272.

181 APPENDICES

182 Appendix A: The published article of the literature review

The full version of this article has been removed due to copy right. Please consult your local library to view the full version. Appendix B: The published article of midwives’ nutrition knowledge, attitudes, and confidence

The full version of this article has been removed due to copy right. Please consult your local library to view the full version. Appendix C: The published article of self-reported nutrition education received by Australian midwives before and after registration Hindawi Journal of Pregnancy Volume 2017, Article ID 5289592, 9 pages https://doi.org/10.1155/2017/5289592

Research Article Self-Reported Nutrition Education Received by Australian Midwives before and after Registration

Jamila Arrish,1 Heather Yeatman,1 and Moira Williamson2,3

1 School of Health and Society, Faculty of Social Sciences, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 2School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 3School of Nursing and Midwifery, Higher Education Division, Central Queensland University, 90 Goodchap Street, Noosaville, QLD 4566, Australia

Correspondence should be addressed to Jamila Arrish; [email protected]

Received 31 March 2017; Revised 7 June 2017; Accepted 16 July 2017; Published 6 September 2017

Academic Editor: Ann M. Mitchell

Copyright © 2017 Jamila Arrish et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Educating midwives to provide nutrition advice is essential. Limited research focuses on midwives’ nutrition education. This paper explores self-reported nutrition education received by Australian midwives before and after registration. It draws on quantitative and qualitative data from a larger online survey conducted with the members of the Australian College of Midwives (response rate = 6.9%, 푛 = 329). Descriptive and content analyses were used. Of the midwives, 79.3% (푛 = 261) reported receiving some nutrition education during, before, and/or after registration. However, some described this coverage as limited. It lacked sufficient focus on topics such as weight management, nutrition assessment, and nutrition for vulnerable groups. Continuing education often occurred through personal initiatives, such as the midwife enrolling in external courses or exploring issues on the Internet and with colleagues. The majority of participants indicated a need for increased nutrition education (94.2%, 푛 = 310) and guidelines tailored for them to provide nutrition advice (87.8%, 푛 = 289). Australian midwives may not be receiving adequate nutrition education to provide nutrition advice. Inclusion of evidence-based nutrition components in midwifery education and regular updates for practising midwives focusing on challenging nutrition issues is required to ensure that they are supported in this important role.

1. Introduction support as a component of antenatal care have recently been reinforced by the World Health Organization [4]. Accumulating research points to links between prenatal diet Pregnant women are considered more accepting of nutri- and maternal and foetal health. Observational studies have tion advice [5]. May et al. [6] found positive changes in the identified an association between healthy diet during preg- dietary behaviour of pregnant women who were provided nancy and reduced gestational weight gain and lower risk of nutrition advice by their health care professionals compared pregnancy complications such as preterm birth, preeclamp- to those who were not. Yet the provision of nutrition advice sia, and reduced foetal growth [1]. Pregnant women have by health professionals to pregnant women is limited, with increased requirements for some nutrients such as folic acid lack of practitioner education being indicated as one of [2] and iodine [3] that might not be obtained from diet alone the obstacles to the provision of such advice [7]. Research and supplementation is recommended. Other important has reported that nutrition education received by doctors is aspects of maternal diet during pregnancy include appro- inadequate [8, 9]; however, midwives’ nutrition education has priate weight gain and weight management, food safety, and received little attention. management of pregnancy symptoms such as nausea and Midwives are one of the primary care providers of prena- vomiting,constipation,andheartburn.Theimportanceof talcareinAustralia.Midwiveshavebeenreportedasthemost nutrition during pregnancy and the importance of nutrition frequent source of health information for Australian pregnant 2 Journal of Pregnancy women [10] and their role in the provision of nutrition midwives’ provision of nutrition advice during pregnancy, advice is clearly defined in the International Confederation their knowledge, attitudes, and confidence in this area [23]. of Midwives Essential Competencies [11]. However, midwives The survey results indicated that 93% of the midwives provide seem to lack adequate nutrition knowledge and skills [12]. nutrition advice to pregnant women but their nutrition This may be attributed to inadequate education provided knowledge and confidence in providing general and specific in midwifery courses [12]. Previous research in the United nutrition-related advice were inadequate. Therefore, more Kingdom and Australia indicated midwives’ lack of education focus needs to be directed to nutrition education received by on some topics such as obesity and weight management [13– midwives [23]. 16] or healthy eating [13]. Prior Australian research also iden- tified that health professionals (including midwives) need 2.4. Survey Items. This paper reports on the seven questions continuing professional education about nutrition during related to nutrition education received by midwives during pregnancy and breastfeeding [17]. midwifery education and/or during practice. The first two A recent Australian study investigating nutrition educa- questions included open-ended components. Participants tion within midwifery programmes using a mixed-methods were asked if they received nutrition education and if yes, to approach incorporating online surveys and interviews with report the number of hours, number of sessions provided, thecoursecoordinatorsoftheprogrammesidentifiedsome and where they were provided. Participants who answered gaps [18]. Although all surveyed programmes included nutri- “yes” to one or both of the questions also were directed to tion content within their curricula, topics taught varied, and provide the details of this education (including information the number of total hours was low. The education seemed to on who provided it and the nutrition topics covered) from a be medically oriented and lacked focus on developing nutri- drop down menu. Midwives’ views were sought on receiving tion assessment skills or providing practical nutrition train- more nutrition education and having guidelines tailored for ing [18]. Additionally, a review investigating online opportu- them to provide nutrition advice, as well as the reasons for nities for professional development in nutrition in Australia such views. Eight demographic questions were included (gen- identified the scarcity of such opportunities and various gaps der, age, midwifery education, years of experience, place of within those available [19]. practice, principal state/territory of work, level of maternity The aim of this study was to explore Australian midwives’ services, and areas of maternity practice). recollections of the nutrition education they received during basic education and following registration and their perspec- 2.5. Analysis. The Statistical Package for the Social Sciences tives regarding their preparation to provide nutrition advice. Software (SPSS) version 22 (Armonk, NY: IBM Corp.) was used to report the quantitative data. Descriptive data were 2. Methods presented using frequencies and percentages. Participants provided additional information via text boxes. This was 2.1. Design. The study used a cross-sectional descriptive analysed in a descriptive manner using content analysis [24]. design. 2.6. Ethical Approval. The University of Wollongong Health 2.2. Participants and Distribution. The members of the Aus- and Medical Human Research Ethics Committee (HE12/009) tralian College of Midwives (ACM) were invited in 2012 granted ethical approval for the study and it was carried out (푛 = 4770) to participate in the study through an invitation in accordance with The Code of Ethics of the Declaration of publishedintheACMnewsletterandanemailinvitation Helsinki [25]. sent through the ACM office. The invitations contained a hyperlink to the survey. Two email reminders were subse- 3. Results quently sent at one month intervals. The survey included an information sheet explaining the purpose of the study and There were 393 responses, 64 of which were excluded (61 for a statement indicating that the participants provided their missingdata,oneaduplicate,oneresponsefromthepilot,and consent if they completed the survey. A power calculation was one electronic), resulting in 329 complete surveys for analysis undertaken, providing an estimated minimum sample size of (finalresponserateof6.9%,329of4770).Table1shows 356, based on a total population of 4770, margin error of 5, the participants’ demographics. The majority were female and a confidence level of 95%. (98.8%, 푛 = 325), more than 50 years of age (45.9%, 푛 = 151), employedforover10years(69.6%,푛 = 229), and resident 2.3. Survey Development. Previous literature [20–22] was in New South Wales and Queensland (52.9%, 푛 = 174), had drawn upon to develop the survey instrument. Five experts, hospital-based midwifery training (53.2%, 푛 = 175), and including two dietitians, two academics (with expertise in were employed in public hospitals (86.6%, 푛 = 285) gener- public health nutrition and midwifery), and a statistician, ally in regional and tertiary referral hospitals (67.7%, 푛= reviewed the survey. The survey was circulated to five 223) rotating through antenatal, birthing, and postnatal areas research colleagues and five practising midwives as a pilot. (41.3%, 푛 = 136). The survey was consequently modified prior to dissemina- Ofthe329respondents,79.3%(푛 = 261)reportedthat tion. Survey Monkey Software was used to create the final for- they had received nutrition information or education during mat online (Survey Monkey Inc., Palo Alto, California, USA, their midwifery education and/or during practice. Table 2 https://www.surveymonkey.com). The full survey examined presents details of the nutrition education received during Journal of Pregnancy 3

Table 1: Characteristics of the respondents.

∗a Characteristics Number of responses (푛 ) Percentage (%) Gender Female 325 98.8 Male 4 1.2 Age 21–30 years 28 8.5 31–40 years 55 16.7 41–50 years 95 28.9 Older than 50 years 151 45.9 Education Bachelor degree of midwifery 74 22.5 Hospital-based training midwifery 175 53.2 Initial midwifery postgraduate degree 80 24.3 Years of experience Less than 2 years 22 6.7 2–5 years 30 9.1 6–10 years 48 14.6 More than 10 years 229 69.6 Principal state or territory of work New South Wales (NSW) 96 29.2 Queensland (QLD) 78 23.7 South Australia (SA) 30 9.1 Tasmania (TAS) 8 2.4 Victoria (VIC) 58 17.6 Western Australia (WA) 40 12.2 Australian Capital Territory (ACT) 8 2.4 Northern Territory (NT) 11 3.3 Principal place of practice Public hospital 285 86.6 Private hospital 16 4.9 Independent midwifery practice 28 8.5 Level of maternity services Community 53 16.1 Rural hospital 53 16.1 Regional hospital 113 34.3 Tertiary referral 110 33.4 b Area of midwifery practice Antenatal care 96 29.2 Birthing (labour) suite 54 16.4 Postnatal 89 27.1 Rotation through all the above areas 136 41.3 Group practice (case load or team midwifery) 67 20.4 Independent midwifery practice 28 8.5 a b ∗ Total number = 329. Multiple responses allowed. The table is reused with permission from Elsevier. midwifery education and/or after registration. It was mainly or calcium; alcohol and pregnancy; and the healthy range provided by midwives (67.4%, 푛 = 176), followed by dieti- of weight gain required for pregnant women during dif- tians/nutritionists (56%, 푛 = 147). Instruction by other health ferent stages of pregnancy (78.9%, 77.0%, and 75.1%, resp.) professionals and organisations and self-directed learning (Table 2). Other nutrition topics included managing nausea, (SDL) also made a contribution (24.5%, 푛=64). constipation, or heartburn; food safety and preparation (e.g., The most frequent nutrition topics covered were nutrition listeria); breastfeeding; and gestational diabetes management. during pregnancy, for example, the role of folate, iodine, Topics reported to a lesser extent were managing weight 4 Journal of Pregnancy

Table 2: Nutrition information/education details. a Nutrition education details 푛 % b The providers of nutrition education Midwives 176 67.4 Dietitians/nutritionists 147 56.3 Obstetricians or other doctors 36 13.8 c Other 64 24.5 Idonotknow 25 9.6 b Nutrition topics covered in the education Topics of nutrition during pregnancy Nutrition during pregnancy, for example, the role of folate, iodine, or calcium 206 78.9 Alcohol and pregnancy 201 77.0 The healthy range of weight gain required for pregnant women during different stages of pregnancy 196 75.1 Nutrition-related issues such as managing nausea, constipation, or heartburn 178 68.2 Food safety and preparation during pregnancy (e.g., listeria) 174 66.7 Nutrition for breastfeeding 173 66.3 Nutrition management of gestational diabetes 164 62.8 Managing weight during pregnancy 115 44.1 Reviewing diet for nutrition requirements of pregnancy 111 42.5 Nutrition during pregnancy and different cultural groups 54 20.7 Nutrition and teenage pregnancy 54 20.7 Topics of general nutrition General nutrient information, e.g. the role of vitamins and minerals in the body 124 47.5 General food safety 95 36.4 General nutrition, for example, prevention of chronic illnesses such as cancer and heart diseases 46 17.6 d Other 10 3.8 a b n = 261 (only midwives who received nutrition information/education during midwifery education or after registration answered this section). Multiple c responses allowed. “Other” included self-directed learning (through internet, media, reading books, journals, and attending conferences), complementary therapists (such as naturopaths and homeopaths), chiropractors, diabetes educators, midwives (colleagues, lecturers, and presenters in conferences or online) drug companies representatives, drug and alcohol staff and nurses, nutrition experts, kinesiologists, International Board Certified Lactationsultant Con d (IBCLC) course educators, governmental organisations, health promotion officers, and interaction with pregnant women. “Other” included nutrition for newborn and infants, nutrition during labour and after birth (especially for women from different cultural backgrounds such as Asian, Muslim, andAfrican women), nutrition for vegetarians and vegans, nutrition for fertility, nutrition for alleviating symptoms such as thrush, eczema, and allergies, nutrition for preconception, the impact of maternal nutrition on child health, and the effects of socioeconomic factors on nutrition status, supplements, and organic food. and reviewing diet for nutrition requirements of pregnancy a year. The nutrition education was offered in a range of edu- (44.1% and 42.5%, resp.). The least covered topics were cational, clinical, and community settings. nutrition during pregnancy and different cultural groups and Thirty-four (10.3%) midwives indicated that the nutri- nutrition and teenage pregnancy (20.7% and 20.7%, resp.). tioneducationprovidedwaslimited,morefocusedonthe General nutrition topics were also covered to a lesser extent, basics or foods to avoid, and mostly integrated with other including the role of vitamins and minerals in the body, topics rather than being presented separately. According to general food safety, and prevention of chronic illnesses such one respondent, such education provided only a very small as cancer and heart disease. In addition to the provided list of amountofinformationaboutfoodsthatpregnantwomen topics, a few midwives added other topics (Table 2). should avoid. (Participant 278) One hundred thirty-three respondents (40.4%) provided Details of their nutrition education during practice were details of their nutrition education during midwifery educa- provided by 149 respondents. Of these, 58 respondents tion. Of these, 42.9% (n = 57) provided approximate number reported the duration of education sessions provided after of hours and/or sessions taught. The number of lectures was registration. Sessions ranged from 20 minutes or an hour for generally small, ranging from 1 to 6 lectures, while numbers of individual lectures/sessions to 120 hours for separate units or hours ranged from 10 minutes to 10 hours. Very few midwives courses. (푛=6) reported receiving extensive coverage of nutrition Self-directed learning (SDL) was reported by 62 mid- (e.g., 30 hours or more), and when they did so, it had usually wives, sometimes as their main or only avenue to obtain been provided as a separate unit that lasted for a semester or nutrition education. Self-directed learning avenues included Journal of Pregnancy 5 attending conferences/workshops; undertaking nutrition Currently unable to refer women to[the] dietitian, courses; reading scientific journals, books, and pamphlets; [due to] (funding)... therefore midwives, espe- and communicating with other health professionals. cially those involved in continuity of care models Some midwives reported receiving in-service nutrition areatthecoalfacetomakechangesgiventhey education (푛=22), while others reported accessing such have the right information and tools to do so. education at their own expense. (Participant 107) None offered. Have accessed 2 day study days at Afewmidwives(푛=4)believedtheydonotreceive own cost. (Participant 282) enough nutrition education despite their being the health professionals with the most contact with pregnant women. Inresponsetothequestiononwhethertheirpractice would benefit from receiving more nutrition information Very little education or resources are directed or education, 94.2% (n =310)ofthemidwivesresponded towardsmidwivesinthisareaandwearethe “yes,” 1.22% (n =4)responded“no,”and4.6%(n =15) health professionals who spend most time with the “have not thought about it.” Of the 329 midwives, 40.1% (n = women. (Participant 311) 132) provided further details. Many of the midwives’ written Some midwives (푛=10)eitherwereopposedtoreceiving responses are related to professional commitment to their more information or had not thought about it or wanted role. Many of the responses (59.1%, n =78)indicatedthat more information but had reservations. Three thought that more nutrition education would help improve their know- dietitians are better positioned to provide specialised advice ledge or keep it up to date, increase their confidence, and help and they should be seen by all pregnant women. Others (푛= them provide evidence-based, consistent advice. 4) thought that even if education was provided, it would Would feel more confident and knowledgeable in need regular updates and might not be possible for every offering appropriate info[information] and advice issue, specific enough, or conveyed to women due to time re [on] diet and nutrition. (Participant 153) constraints. One midwife exhibited a lack of confidence in current dietary guidelines. A smaller group of midwives (푛=16)includedcom- ments that reflected a broad perspective of the importance of YesIwouldliketodomorestudyre[on]nutrition nutrition support to the health of the mother, baby, and the but I am not confident that our current dietary whole family. guidelines are leading our society to greater health and so I would not be keen to study “mainstream” Diet is key to good health and if we teach the dietary information. I believe though that good mother how to eat right then we impact the nutritionisthebasisforgoodhealthandsois whole family. We also reduce the complications an essential aspect of pregnancy care. (Participant of pregnancy if we get good diet and weight 232) management. (Participant 287) Some midwives (푛=14)indicatedarangeoftopicsthey Some midwives (푛=10) expressed a desire for greater wouldliketohavecoveredinongoingeducation,including nutrition knowledge to help them provide accurate informa- obesity, gestational diabetes, nutrients, diets for women from tion in regard to more specific pregnancy-related issues, such different cultural backgrounds or women living in remote as the prevention and management of obesity and diabetes, areas, special diets, weight loss for postpartum women, and as well as allergies, and nutritional challenges associated with exercise. Three types of education were suggested by six theculturallydiversewomenpresenting. midwives: hard copy information and references; guidelines in an easy access format; and regular updates such as in- Weareseeingmoreobesewomenanditisdifficult service and professional development sessions. to give them advice on weight management during The majority of the respondents (87.8%, 푛 = 289)thought pregnancy. (Participant 115) that Australian midwives would benefit from guidelines specifically tailored for them to provide pregnant women Ten midwives specifically expressed their belief that it was with nutrition advice; 3% (푛=10) disagreed, while 9.1% part of their professional role to provide nutrition advice to (푛=30) had not thought about it. When asked to explain pregnant women. their answers, 36.2% (푛 = 119) responded. Their explanations Midwives are often the first contact a mother has for why nutrition guidelines could be beneficial included that with a health professional during her pregnancy the guidelines would encourage midwives to provide more and should be given every opportunity to expand evidence-based, consistent advice and reduce conflicting 푛=52 knowledgeandgivethebestadvicetomothersand information for both midwives and women ( ). It their families. (Participant 208) would also overcome the lack of clinical guidelines specific to Australia, unlike those for smoking and diabetes (푛= Structural constraints also prompted midwives desire to 9). Given the importance of nutrition and midwives’ role in seek greater nutrition education (n = 4); For example, their nutrition advice (푛=15), clinical guidelines would overcome role was considered particularly important due to limited midwives’ lack of nutrition knowledge, the current failure to availability of dietitians’ services. uniformly provide adequate nutrition education in midwifery 6 Journal of Pregnancy education and practice, and limited access to dietitians (푛= hoursofnutritioneducationinhalfoftheprogrammeswas 10). only 5 to >10 hours, with only two programmes having a separate nutrition unit. There was also a lack of approaches to Things work so much better when we eliminate develop nutrition assessment skills or have practical nutrition ... some of the shades of grey a consistent guideline training [18]. would be terrific in many areas of maternity care, Limited nutrition education in midwifery programmes notjustnutritionadvice.(Participant48) raises the need for those providing preregistration education to review their coverage of nutrition. Midwives’ nutrition Asmallnumber(푛=19) were in favour of guidelines knowledge has been significantly linked to nutrition educa- tailored to their requirements but they had some reservations, tion received during their initial education [23]. However, it while 18 midwives were not in favour of guidelines tailored is unrealistic to assume that preregistration nutrition content to midwives’ needs or had not thought about it. Reservations should suffice for all future practice, as professional know- about such guidelines included the need for such guidelines ledge is dynamic, evolving in line with the evidence base. to be evidence-based, user-friendly, and women-centred (and Thus the role of preregistration nutrition education in imple- in one case have a naturopathic holistic approach), involve menting necessary knowledge and skills that can be improved midwives in their development, and be regularly updated. during practice cannot be ignored. Onemidwifecommentedthattherearealreadyavailable Severalchallengeshavebeenidentifiedintheliterature guidelines while another thought guidelines may restrict that impact effective integration of nutrition education within advice given. health professionals’ education including obtaining time Guidelines can be useful. However, yet another within the curricula to integrate nutrition; focusing on teach- “tick box” would be annoying. Guidelines can ing the role of nutrients in metabolic pathways rather than potentiallyleadtoprohibitivepractice.(Partici- focusing on practical food-based knowledge; lack of empha- pant 30) sis on nutrition; lack of involving nutrition experts; and a lack of resources [26]. A competency-based nutrition educa- Further reasons given against guidelines included that tion addressing clinical and public health nutrition and inter- midwives need to collaborate with other health professionals professional collaboration have been suggested as strategies (e.g., dietitians); and learning should be encouraged rather to tackle these challenges [27]. than merely relying on guidelines. In response to the lack of subsequent formal opportuni- ties for nutrition education during practice, many of the mid- My concern would be a one size fits all doesn’t wives reported that they undertook self-directed learning or work for everyone, what is out there tends to independent learning. Such learning [28] assumes that adult be very middle-class/income, Anglo-Saxon, older/ learners are mature, independent, self-directed, responsible, motivated women centric. Teenagers will tell you and individual, and their learning is connected to their social they choose the healthy options at McDonald’s roles and previous experiences, so they need approaches (and mean it!). (Participant 91) where they are partners rather than passive receivers [29]. The overwhelming availability of new content (such as new areas 4. Discussion of nutrition information) and competency-based education have increased the interest in SDL [29]. Although SDL is con- ThisstudyexploredAustralianmidwives’ownaccountsofthe sidered as the most suitable model for health professionals to nutrition education they had received. The majority reported keep their knowledge up to date, there are mixed results about receiving some nutrition education during midwifery educa- the effectiveness of SDL models compared to traditional tion and/or after registration; however, this education lacked learning models [30]. It was found that it is more effective focus on contemporary nutrition issues and was generally in improving knowledge than attitudes and skills [30]. It is described as limited. The provision of nutrition education to also more suitable to advanced learners [29]. There are also the midwives was reported to be mainly provided by mid- no consistent means to determine the learner readiness to wives with further involvement of professionals with relevant SDLandthenatureofthecontentmostappropriatetoSDL expertise, such as dietitians and to a lesser extent by obste- [29]. tricians or other doctors. Some midwives reported attempt- The majority of the midwives in this study were mature ing to address their lack of formal nutrition education inageandthismightbethereasonforreferringtoSDLasa through self-directed learning. The majority indicated a need way of obtaining nutrition education. However, the suitability for increased nutrition education and guidelines tailored for ofSDLinnutritioneducationremainsunknownforyounger them to provide nutrition advice. midwives specifically and for midwives in general. Further Midwives generally commented that the coverage of nut- research in this regard is needed. From our study self-directed rition during midwifery education was limited, integrated learningseemedtoinvolvesomeissuessuchastheoutlay within other topics, and focused on the basics. The reported of personal funds (not all midwives may be in a position to number of lectures and/or hours was small. Few midwives doso)andthevariablequalityofthenutritioneducation reported having a separate unit covering nutrition during received. Midwives would benefit from being offered afford- pregnancy. Recent research [18] surveyed Australian accred- able and easily accessible nutrition education from trusted ited midwifery programmes and found that the number of midwifery organisations and their workplaces. Access to Journal of Pregnancy 7 information from dietitians as the experts in the field would in the understanding of the importance of nutrition during also benefit midwives. pregnancy or the changes in midwifery practice, such as Other midwives were the main providers of nutrition increasing numbers of women with obesity or diabetes, or the education to the participants. However, it was identified that greater diversity of vulnerable women. midwives may themselves receive limited education in nutri- Midwives in this study believed in the importance of tion. The provision of nutrition education by professionals nutrition during pregnancy and their role in providing with relevant expertise, such as dietitians, was mentioned by advice and therefore their need for more nutrition education around 60% of the midwives. This is not unexpected, as dieti- andspecificguidelines.Therealisationbythemidwivesof tians were found to be rarely involved in teaching nutrition the need to provide evidence-based, consistent advice is content within Australian midwifery programmes [18]. Other understandable. There is currently an overwhelming amount research has suggested that collaboration between dietitians of nutrition information available in the media, particularly and midwifery academics in terms of nutrition education on the Internet, with many confusing messages that are not for midwives is feasible and could help improve midwives’ scientifically proven. Nutrition science continues to develop nutrition knowledge [31]. and new information is constantly emerging. This presents Variable nutrition coverage within midwifery education challenges for busy midwives. Formal updates from official and/or after registration may result in variable quality of mid- organisations such as the ACM and their workplaces would wifery practice in this important area. Primarily it focused ensure that midwives are up to date with the latest evidence- on basic and theoretical topics. Complex topics and those based advances in nutrition. Prior research has also shown incorporating practical or management skills (such as weight that midwives’ knowledge and confidence could be improved management and reviewing diet for nutrition requirements through compact training [22, 36]. Unfortunately, there is of pregnancy) were reported less frequently. Similar results lack of the availability or provision of such intensive training have been reported previously [21, 32]. According to the ICM in Australia [19]. Essential Competencies, midwives should have the knowl- Strategies for providing continuing education (e.g., online edge/skills to assess women nutritionally [11]. The ability of nutrition education) have some advantages, such as reaching midwives to manage weight is essential given the high rates a wide audience with high-quality content; being an efficient, of overweight and obesity among childbearing women [33]. relatively low-cost method of delivery; providing convenient, Midwives in this study listed the increasing rates of obesity self-paced study; and being effective at building capacity. as a reason for the need for greater nutrition information However,itrequiresfundstodevelopandsustain[26]. and specific guidelines. A previous study has found that Aus- Unless there are initiatives from the government and the tralian midwives using evidence-based guidelines to manage professional bodies to provide such training, continuing obesity were more likely to report adequate education and nutrition education for health professionals will remain a greater confidence in counselling [34]. challenge. Of concern was the identification of the least covered At the time of administrating the survey, the only avail- nutrition topics, particularly nutrition for different cultural able dietary guidelines were the Australian Dietary Guide- groups, and nutrition and teenage pregnancy. Pregnant lines (2003, revised in 2013) which were general guidelines women from different cultural backgrounds and pregnant and did not include advice specific to particular health pro- teenagers are nutritionally vulnerable groups [2]. The results fessionals, such as midwives (who are not extensively trained of this study are consistent with previous international in nutrition), on how to provide nutrition advice to pregnant research that found that midwives lacked sufficient knowl- women.In2012and2014,AustraliareleaseditsfirstNational edgeandskillstocounselpregnantwomenfromdifferentcul- Antenatal Clinical Guidelines [37, 38]. A small number of tures [35]. Midwives specifically pointed out that they would the midwives expressed reservations regarding guidelines benefit from greater knowledge/clinical guidelines and in- tailored to midwives’ needs and one midwife exhibited a lack service education on diets of women from culturally diverse of confidence in current dietary guidelines, which may reflect backgrounds that would help them in these circumstances. a tension between her personal views and her professional It was not possible to distinguish which phase, either role. Future research could explore the views of midwives during midwifery education or practice, the midwives were on the National Antenatal Clinical Guidelines; the support referring to in their answers to the questions regarding the midwives should receive to incorporate the guidelines into providers of nutrition education and the topics covered. Fifty- midwifery practice; and the extent to which they are consis- seven percent of the midwives were aged 41 and older; thus tent with their expectations of their professional roles. theymayhavereceivedtheirmidwiferyeducationsometime ago and 50% of the midwives reported that they had gained 4.1. Limitations and Strengths. While the response rate was their education through the now abandoned hospital-based low (6.9% of the members of ACM), it was similar to training rather than through university education. However, apreviousstudyconductedwiththiscohort[34].Online the pattern of topics reported as included within their surveystendtohavelowerresponseratescomparedtomailed received nutrition education was similar to topics reported surveys[39].Themajorityofthemidwiveswereofmature tobecoveredincontemporaryAustralianmidwiferypro- age. Therefore, many were not able to provide the details of grammes [18]. This may imply little change in the pattern of the nutrition education they received during their midwifery nutrition topics covered within midwifery education. It may education several decades earlier. This may be due to the use not reflect the changes in nutrition knowledge and advances of open-ended questions to obtain such data. The authors 8 Journal of Pregnancy chose to use open-ended questions to give the participants Acknowledgments the freedom of reporting their own experiences instead of providing limited certain answers. The use of both quantita- The authors would like to thank the members of the ACM tive and qualitative data is strength of this study. Quantitative who completed the survey and Ms Elaine Newby who data revealed that about 80% of the midwives received provided editing assistance. This project was part of a doctoral some nutrition education during midwifery education and/or scholarship for J. Arrish which was funded in part by the practice but the qualitative data highlighted the shortcomings Libyan Government. This research has also been conducted of this education. The varying responses to the various with the support of the Australian Government Research questions eliciting midwives’ perceptions and needs did not Training Programme Scholarship. permit exploration of associations of such responses with demographics or work characteristics of the participants. References [1] A. L. Brantsæter, M. Haugen, R. Myhre et al., “Diet matters, par- 4.2. Practical Implications. National general recommenda- ticularly in pregnancy-results from MoBa studies of maternal tions can be made to include nutrition in a systematic way in diet and pregnancy outcomes,” Norsk Epidemiologi,vol.24,no. midwiferyprogrammesthroughtheAustralianNursingand 1-2, pp. 63–77, 2014. Midwifery Accreditation Council. Midwives need continuous [2]C.S.Williamson,“Nutritioninpregnancy,”Nutrition Bulletin, support from official and trusted organisations, such asthe vol.31,no.1,pp.28–59,2006. ACM and their workplaces, to provide them with regular [3] NHMRC, “Iodine supplemntation for pregnanct and breast- evidence-based nutrition updates, especially in terms of feeding women, 2010,” https://www.nhmrc.gov.au/guidelines- contemporary issues such as obesity. These recommendations publications/new45. can be applicable internationally through similar official [4] World Health Organization, WHO recommendations on ante- midwifery organisations. natal care for a positive regnancy experience .I,WorldHealth Organization. 4.3. Future Research. Younger midwives were underrepre- [5] E. M. Szwajcer, G. J. Hiddink, M. A. Koelen, and C. M. J. sented in this study; future research should focus on inves- van Woerkum, “Written nutrition communication in midwifery tigating newly graduated midwives’ perceptions of nutrition practice: What purpose does it serve?” Midwifery,vol.25,no.5, education received during midwifery education and learning pp. 509–517, 2009. objectives regarding nutrition education within midwifery [6] L. May, R. Suminski, A. Berry, E. Linklater, and S. Jahnke, “Diet programmes to explore if skills to deal with challenging and pregnancy: health-care providers and patient behaviors,” issues such as obesity are included in the curricula. Future TheJournalofPerinatalEducation,vol.23,no.1,pp.50–56,2014. studies also might explore the actual nutrition education [7] C. Lucas, K. E. Charlton, and H. Yeatman, “Nutrition advice being provided in midwifery programmes and how to make during pregnancy: do women receive it and can health profes- changes to curricula to facilitate the incorporation of nutri- sionals provide it?” Maternal and Child Health Journal,vol.18, tion education and the range of information that women seek no.10,pp.2465–2478,2014. from midwives, to ensure that the nutrition education within [8]K.M.Adams,W.S.Butsch,andM.Kohlmeier,“Thestate programmes is relevant. of nutrition education at US medical schools,” Journal of Biomedical Education,vol.2015,ArticleID357627,7pages,2015. 5. Conclusion [9]K.M.Adams,M.Kohlmeier,M.Powell,andS.H.Zeisel, “Invited Review: Nutrition in medicine: nutrition education for Australian midwives may not be adequately prepared to pro- medical students and residents,” NutritioninClinicalPractice, vide nutrition advice, a role that is increasingly important due vol.25,no.5,pp.471–480,2010. to greater number of pregnant women with nutrition-related [10] H. A. Grimes, D. A. Forster, and M. S. Newton, “Sources of issues. Limited coverage of nutrition within midwifery or information used by women during pregnancy to meet their information needs,” Midwifery,vol.30,no.1,pp.e26–e33,2014. continuing education was reported, with personal initiatives undertaken to address nutrition information gaps. A more [11] International Confederation of Midwives, Essential compe- tencies for basic midwifery practice, International Confedera- systematic approach aimed at ensuring that all midwives tion of Midwives, 2010, http://www.internationalmidwives.org/ have the basic nutrition knowledge and skills they require to assets/uploads/documents/CoreDocuments/ICM%20Essential provide nutrition advice to pregnant women, as outlined in %20Competencies%20for%20Basic%20Midwifery%20Practice the new Australian Antenatal Clinical Guidelines, is required. %202010,%20revised%202013.pdf. [12]J.Arrish,H.Yeatman,andM.Williamson,“Midwivesand Disclosure nutrition education during pregnancy: a literature review,” Women and Birth,vol.27,no.1,pp.2–8,2014. The Libyan Government was not involved in any part of the [13]D.J.Lee,C.L.Haynes,andD.Garrod,“Exploringthemidwife’s study. role in health promotion practice,” British Journal of Midwifery, vol.20,no.3,pp.178–186,2012. Conflicts of Interest [14]N.Heslehurst,S.Russell,S.McCormack,G.Sedgewick,R. Bell, and J. Rankin, “Midwives perspectives of their training The authors declare that there are no conflicts of interest and education requirements in maternal obesity: a qualitative regarding the publication of this paper. study,” Midwifery,vol.29,no.7,pp.736–744,2013. Journal of Pregnancy 9

[15] S. A. Wilkinson, D. Poad, and H. Stapleton, “Maternal over- [33] Australian Bureau of Statistics, Gender Indicators, Australia, weight and obesity: a survey of clinicians’ characteristics and 2013, http://www.abs.gov.au/ausstats/[email protected]/Lookup/4125.0main attitudes, and their responses to their pregnant clients,” BMC +features3330Jan%202013. Pregnancy and Childbirth,vol.13,article117,2013. [34] M. A. Biro, R. Cant, H. Hall, C. Bailey, S. Sinni, and C. East, [16]J.C.Willcox,K.J.Campbell,P.vanderPligt,E.Hoban,D. “How effectively do midwives manage the care of obese preg- Pidd, and S. Wilkinson, “Excess gestational weight gain: an nant women? A cross-sectional survey of Australian midwives,” exploration of midwives’ views and practice,” BMC Pregnancy Women and Birth,vol.26,no.2,pp.119–124,2013. and Childbirth,vol.12,no.1,article102,2012. [35] A. L. Wennberg, K. Hamberg, and A.˚ Hornsten,¨ “Midwives’ [17] R. Hughes, J. Maher, E. Baillie, and D. Shelton, “Nutrition and strategies in challenging dietary and weight counselling situa- physical activity guidance for women in the pre- and post-natal tions,” Sexual and Reproductive Healthcare,vol.5,no.3,pp.107– period: a continuing education needs assessment in primary 112, 2014. health care,” Australian Journal of Primary Health,vol.17,no. [36]A.Basu,L.Kennedy,K.Tocque,andS.Jones,“Eatingfor1, 2, pp. 135–141, 2011. Healthy and Active for 2; feasibility of delivering novel, compact [18]J.Arrish,H.Yeatman,andM.Williamson,“NutritionEduca- training for midwives to build knowledge and confidence in tion in Australian Midwifery Programmes: A Mixed-Methods giving nutrition, physical activity and weight management Study,” JournalofBiomedicalEducation,vol.2016,pp.1–12,2016. advice during pregnancy,” BMC Pregnancy and Childbirth,vol. [19] State of Queensland Queensland Health, Maternal and infant 14, no. 1, article no. 218, 2014. nutrition e-Learning platforms review, Children’s Health [37] Australian Health Ministers’ Advisory Council, Clinical Practice Queensland Hospital and Health Service, 2015. Guidelines: Antenatal Care – Module 1, Australian Government [20]C.M.Mulliner,H.Spiby,andR.Fraser,“Astudyexploring Department of Health and Aging: Canberra, 2012, http://www midwives’ education in, knowledge of and attitudes to nutrition .health.gov.au/antenatal. in pregnancy,” Midwifery,vol.11,no.1,pp.37–41,1995. [38] Australian Health Ministers’ Advisory Council, Clinical Prac- [21] S. Elias and T. Green, “Nutrition knowledge and attitudes of ticeGuidelines:AntenatalCare–Module2,AustralianGov- New Zealand registered midwives,” Nutrition and Dietetics,vol. ernment Department of Health and Aging: Canberra, 2014, 64, no. 4, pp. 290–294, 2007. http://www.health.gov.au/antenatal. [22] D. Barrowclough and F. Ford, “A nutrition open- learning pack [39] P. Leece, M. Bhandari, S. Sprague et al., “Internet versus mailed for practising midwives,” Nutrition & Food Science,vol.31,no. questionnaires: A randomized comparison (2),” Journal of Med- 1, pp. 6–12, 2001. ical Internet Research,vol.6,no.3,2004. [23] J.Arrish,H.Yeatman,andM.Williamson,“Australianmidwives and provision of nutrition education during pregnancy: a cross sectional survey of nutrition knowledge, attitudes, and confidence,” Women and Birth,vol.29,no.5,pp.455–464,2016. [24] S. Elo and H. Kyngas,¨ “The qualitative content analysis process,” Journal of Advanced Nursing,vol.62,no.1,pp.107–115,2008. [25] World Medical Association, WMA declaration of Helsinki: Ethical principles for medical research involving human subjects, 2013, http://www.wma.net/en/30publications/10policies/b3/. [26] R. A. Dimaria-Ghalili, M. Edwards, G. Friedman et al., “Capac- ity building in nutrition science: revisiting the curricula for medical professionals,” Annals of the New York Academy of Sciences,vol.1306,no.1,pp.21–40,2013. [27] P. M. Kris-Etherton, S. R. Akabas, P. Douglas et al., “Nutrition competencies in health professionals’ education and training: A new paradigm,” Advances in Nutrition,vol.6,no.1,pp.83–87, 2015. [28] M. Knowles, Self-Directed Learning: A guide for learners and teachers, Associated Press, New York NY, 1975. [29] M. H. Murad and P. Varkey, “Self-directed learning in health professions education,” Annals of the Academy of Medicine Singapore,vol.37,no.7,pp.580–590,2008. [30] M. H. Murad, F. Coto-Yglesias, P. Varkey, L. J. Prokop, and A. L. Murad, “The effectiveness of self-directed learning in health professions education: A systematic review,” Medical Education, vol.44,no.11,pp.1057–1068,2010. [31] S. Elias and S. Stewart, “Developing nutrition within the midwifery curriculum,” British Journal of Midwifery,vol.13,no. 7,pp.456–460,2005. [32] J. McNeill, J. Doran, F. Lynn, G. Anderson, and F. Alderdice, “Public health education for midwives and midwifery students: a mixed methods study,” BMC Pregnancy and Childbirth,vol.12, no. 1, article 142, 2012. M EDIATORSof INFLAMMATION

The Scientific Gastroenterology Journal of Research and Practice Diabetes Research Disease Markers World Journal Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of International Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Submit your manuscripts at https://www.hindawi.com

BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of Obesity

Evidence-Based Journal of Stem Cells Complementary and Journal of Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Parkinson’s Disease

Computational and Mathematical Methods Behavioural AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Appendix D: The published article of midwives’ role in providing nutrition advice during pregnancy

Hindawi Nursing Research and Practice Volume 2017, Article ID 7698510, 11 pages https://doi.org/10.1155/2017/7698510

Research Article Midwives’ Role in Providing Nutrition Advice during Pregnancy: Meeting the Challenges? A Qualitative Study

Jamila Arrish,1 Heather Yeatman,1 and Moira Williamson2,3

1 School of Health and Society, Faculty of Social Sciences, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 2School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 3School of Nursing and Midwifery, Higher Education Division, Central Queensland University, 90 Goodchap Street, Noosaville,QLD4566,Australia

Correspondence should be addressed to Jamila Arrish; [email protected]

Received 31 March 2017; Accepted 24 May 2017; Published 2 July 2017

Academic Editor: Maria Horne

Copyright © 2017 Jamila Arrish et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This study explored the Australian midwives’ role in the provision of nutrition advice. Little is known about their perceptions of this role, the influence of the model of care, and the barriers and facilitators that may influence them providing quality nutrition advice to pregnant women. Semistructured telephone interviews were undertaken with a subsample (푛=16) of the members of the Australian College of Midwives who participated in an online survey about midwives’ nutrition knowledge, attitudes, and their confidence in providing nutrition advice during pregnancy. Thematic descriptive analysis was used to analyse the data. Midwives believed they have a vital role in providing nutrition advice to pregnant women in the context of health promotion. However, this was not reflected in the advice many of them provided, which in many accounts was passive and medically directed. The extent and efficacy of their role appear to be challenged by many structural barriers. Midwives suggested facilitators that may assist in overcoming these challenges. Midwives need assistance, support, and guidance to provide holistic nutrition advice that assists women to achieve healthy pregnancies. A collaborative approach between midwifery bodies, nutrition and education experts, and maternity care services may provide an effective way forward.

1. Introduction challenged by factors such as limited time, resources, and education [8]. The short and long term impacts of maternal diet onthe Midwives are health care professionals perceived to be health of the mother and the foetus are widely documented in a unique position to provide nutrition advice to preg- [1, 2]. Pregnant women’s dietary behaviour is influenced nant women due to their usual contact with the women by interpersonal, institutional, and community factors [3]. via antenatal appointments. Moreover, health promotion Nutrition knowledge is one of those numerous factors that and education are considered among the most important may affect women’s diet [3] and pregnant women are per- activities that midwives perform with pregnant women as ceived to be more receptive of nutrition information during advocates for health and wellbeing rather than managers pregnancy [4]. Nutrition education during pregnancy has of diseases [9]. However, studies in the United Kingdom been linked to positive maternal and infant outcomes [5], (UK) [10] and Sweden [11] reported that midwives struggle especially among overweight and obese women [6]. In spite to provide dietary advice, especially in the context of health of these positive links, the provision of nutrition advice by promotion and on challenging issues such as obesity, despite antenatal care providers is not common practice [7]. In the acknowledging it as part of their role [10]. literature, this lack of engagement with women in discussing A recent Australian quantitative study reported that the their diet has been attributed to health care providers being majority of the midwives believed that their role in providing 2 Nursing Research and Practice nutrition advice is significant and the majority reported pro- the study, its significance, what the participants will do, the viding nutrition advice to pregnant women. However, some approximate time that will be taken for the interviews, and midwives provided written comments specifying barriers theparticipants’righttorefusetoparticipateorwithdraw such as lack of time, resources, and the model of care cur- from the study with their data at any time without any effect rently utilised as affecting their provision of such advice [12]. on their relationship with the University of Wollongong or This study aimed to gain further understanding of mid- their place of employment. The participants were offered wives’ perceptions of their role, particularly the effect of the the opportunity to review their transcripts if they wanted. model of care on the way they provide nutrition advice, the How the data will be disseminated was also explained. barriers that hinder their role, and the facilitators that may The participants were also given the details of the ethics help them to provide better nutrition advice to pregnant committee of the university who they could approach with women. These insights will contribute to pregnant women anyconcerns.Theyweregiventheopportunitytoaskany receiving quality nutrition advice and support to help them questions at any stage. Reminders to nonrespondents were make informed decisions about their diets. sent in November 2012 and January 2013. Participants who returned their signed consent forms were sent a form to 2. Methods indicate their preferred option for the interview (Skype or telephone), provide their phone if they chose the telephone or 2.1. Design. A qualitative descriptive approach was under- their Skype account’s details if they chose Skype, and provide taken to gain an in-depth understanding of midwives’ per- their preferred dates for the interview. ception of the importance of nutrition, how they learnt about nutrition, and how they educate women. The approach is 2.4. Data Collection. The primary researcher (JA) conducted useful when the aim of the research is to describe participants’ the semistructured telephone interviews between October experiences and perceptions regarding a particular topic, as is 2012 and March 2013. The interviews were audio-recorded. the aim of this research [13]. In the process of analysing the The length of the interviews averaged 21 minutes. The main data and presenting them, there is rich and straightforward questions that were used as a guide during the interviews were description of the participants’ experiences or related events as follows: [13].Theanalysisinthisapproachallowsforreasonable interpretation but the researcher stays close to the data and (1) Can you please describe the model of care you participants’ own language [13]. Semistructured interviews follow/practise as a midwife? were employed. The interviews were flexible in style and (2) I would be interested to hear your views of how structured around an interview guide and also included other food selection and nutrition during pregnancy could probing questions that may arise during the interview. The influence pregnancy outcomes. questions were open-ended in nature, allowing respondents to give their answers in their own words and to express (3) What are the most important food issues that you their ideas and opinions. The purpose of a semistructured usually discuss with pregnant women during their interview is to generate rich and candid data that lead to a antenatal visits? What are the issues that should be deeper understanding of an issue [14]. discussed from your point of view? (4)Inwhatwaysdoyouthinkyourmodelofcareaffects 2.2. Sampling and Participants. The participants were a con- the way you provide nutrition advice? venience subsample of the members of the Australian College of Midwives (ACM) who participated in an online survey (5)Pleasedescribeformetheroleyouthinkmidwives about midwives’ nutrition knowledge, attitudes, and their should have in regard to providing food-related or confidence in providing nutrition advice during pregnancy nutrition advice to women during pregnancy? in 2012 [12]. (i) What preparation do you think midwives receivetoprovidesuchadvice? 2.3. Recruitment. In the participant information page of the midwives’ online survey, an introduction about follow-up (ii) What are the barriers that midwives encounter interviews was provided and a note was also included at the in relation to providing such advice? endofthesurvey.Midwivesweredirectedtoaseparatepage (iii) What guidelines or sources of information are to indicate their consent to be contacted for the follow-up available to midwives relating to providing interview and to provide their contact details (i.e., names nutrition information to pregnant women? and email addresses). The intention was to gain the views of midwives across different ages and experiences. Therefore, (6) What might assist midwives to provide better services the participants were asked to indicate their age category (i.e., for pregnant women in regard to food-related or younger than 35 or older than 35) and include their years nutrition advice? of experience. The invitations for the interviews (including (7) Would you like to add anything else? the participation information sheet and the consent form) wereformallysentinOctober2012tothemidwiveswhohad Further questions or prompts derived from the interviews indicated their consent to being contacted for the follow- were used as relevant. The interview guide was developed up. The participant information sheet explained the aim of byJA.Thedevelopmentoftheguidewasinformedby Nursing Research and Practice 3 the literature and the aim to deepen the understanding of 3.2. Perceptions of Midwives’ Role in Providing Nutrition the findings of the survey. The coresearchers, two experts Advice. The majority of the participants perceived the pro- (midwifery and public health), and a dietitian reviewed the vision of nutrition advice to pregnant women as a vital part interview guide to determine its relevance to achieve the aims of the midwives’ role. They considered that midwives have a of the study. unique opportunity to do so as they are the health profession- als who have the most contact with pregnant women. Some 2.5. Data Analysis. All interviews were transcribed verbatim midwives indicated that this opportunity would be greater in by a professional transcriber. The interviews were then a midwifery-led model of care. checked for accuracy by the primary researcher (JA). The Ithinkmidwivesarehealthpromoters....Health SoftwareQSRInternational’sNVivo11wasusedtomanage educators.... I think midwives have a unique the data. Thematic descriptive analysis was used [15]. The opportunity to engage with women at that level transcripts were read and reread by JA to ensure familiarity andifyou’reproviding,ifyou’reacontinuityof with the data and the audio recordings were referred to fre- carer, so that means that a woman’s having care quently to interpret the answers in their actual context. Open from a known midwife then basically throughout coding of the transcripts was undertaken inductively. Two the pregnancy you can establish a relationship of researchers (JA and MW) undertook independent coding trust and respect, and then you can work with the to ensure agreement of coding and establish validity and women more closely with regards to their specific rigor. When disagreement existed, the coding was discussed lives.... support her to provide good nutrition for between the researchers until consensus was reached. JA her family. (Midwife 1) completed the analysis, organised the descriptive themes, and verified them with all coresearchers. There was a general consensus that midwives are the “first port of call” and not the experts, so they provide general or 2.6. Ethical Considerations. The University of Wollongong basic nutrition advice within the context of health promotion Health and Medical Human Research Ethics Committee and primary health care. Providing nutrition advice for spe- approved the study (HE12/009). In the participation infor- cific or complex issues is the role of the experts, “dietitians.” mation page of the online survey, the interested midwives Ithinkmidwivesarethefirstportofcall....Ithink were assured that their personal details would be secure if the midwives can provide the basic information they decided to participate and their anonymity would be and if there is a particular problem or if there’s a reserved. All participating midwives sent their signed consent lady [who] has got a particular dietary problem forms either by email or through the post via the means of that’s when you would refer to a specialist, a prepaid envelopes. A verbal confirmation was also indicated dietitian. (Midwife 2) at the beginning of the interviews. Despite believing in their role in providing nutrition advice, 3. Findings some midwives pointed out that the extent of this role either depends on the model of care or practice setting or is largely 3.1. Participants. Fifty-two midwives consented to be con- restricted by many barriers such as time and model of care. tacted for the interviews and provided their contact details. Nineteen midwives signed their consent forms and sent them Well,inanidealworldpregnantwomenin ... back but three midwives did not send the forms of dates and Australia would have midwifery-led care from other details despite multiple contacts. Hence 16 midwives conception right through pregnancy til 6 weeks ... (all of which were female) participated in the study and afterwards .Soit’djustbeagradualosmosis no selection criteria were applied. All, but one, midwives of information throughout the pregnancy on diet were older than 35 years of age. The participants’ years of and, you know, alcohol and nicotine and it’d just experience ranged from 2 years to 37 years. Table 1 shows be gradual. (Midwife 14) the models of care that the midwives specified they were employed in. The midwives worked in a variety of settings 3.3. Effect of Model of Care on the Provision of Nutrition Advice including public hospitals, private hospitals, private practice, hospital and community antenatal clinics, and birth centres. 3.3.1. Continuity of Care versus Fragmented Care. Midwives Some midwives had one role, while others had more than one in midwifery-led continuity of care models believed that role. For some midwives, antenatal care was their main area the best advantage of their model of care was the ability of work and expertise while others rotated through different to build a relationship with the women based on trust, areas (i.e., birthing suite and postnatal care). Some midwives respect, and confidence. In this context, the woman would worked individually while others worked in teams. Seven of feel comfortable talking about her dietary behaviour with the the midwives specified that their models provided continuity midwifeandthemidwifewouldfeelcomfortableapproaching of care, while eight midwives did not work in continuity the woman to provide woman-centred advice. They also of care models but rather provided fragmented care. One thoughtthatcontinuityofcaremodelsallowedmoretime midwife had two roles providing both continuity of care and fortheprovisionofverbal,gradual,anddeepernutrition fragmented care. information that could be absorbed by the woman. 4 Nursing Research and Practice

Table 1: Midwives’ specified models of care.

Midwife Models of care as specified by the midwives number Midwife 1 The team leader, midwifery-led model of care/continuity of care Midwife 2 Lactation consultant/also has a private practice/does antenatal care but works mostly in postnatal care Midwife 3 Caseload/continuity of care Midwife 4 Community-based model/continuity of care Hospital/rotate through different areas and does antenatal clinic/fragmented care/had been doing Midwife 5 antenatal care for a few months Midwife 6 Private hospital/see women at booking only Midwife 7 Midwifery-led care/continuity of care Midwife 8 Hospital/midwifery educator/does antenatal clinic/fragmented care Midwife9 Privatepracticeforanobstetrician/fragmentedcare Hospital/rotate through different areas/fragmented care/also a clinical midwife for midwifery model of Midwife 10 care for Aboriginal and Torres Strait Islander women Public hospital/fragmented care/mainly antenatal care in an Aboriginal health clinic and a midwives’ Midwife 11 clinic in the country/also has private practice Midwife 12 Community-based/continuity of care Midwife 13 Team midwifery/birth centre/continuity of care Midwife 14 Hospital/educator/does antenatal classes/used to work in clinical area Multidisciplinary team of midwives with residents and consultants/rotate through the Midwife 15 clinic/fragmented care Midwife 16 Midwifery Group Practice (Caseload)/continuity of care

...I’vegotalotoftimetospendwiththem....I of care midwifery models, on the other hand, felt affected by get the feeling that they trust me and that they many factors in the way they provided nutrition advice. Most would trust my advice.... Because I see them signalled that their model of care did not allow enough time, regularly, I can give them just bite size amounts opportunities, or early involvement to build a relationship ofinformationwhichcanbeabsorbedquitewell with the women and provide effective education. rather than great lumps of stuff. Also most of it’s ... a verbal education therefore there’s not all the if you know that you’re going to see them written stuff so I’m not relying on their literacy a few more times, then you can actually build skills. (Midwife 12, community-based/continuity a relationship and then start to build up your of care model) rapport and their trust in you to the point where they’re going to be willing to accept what you have One midwife thought of nutrition as a means to help improve to tell them. (Midwife 5, hospital/rotating through birth outcomes for her home birth women. all areas and does antenatal clinic/fragmented Well,it’sveryimportanttomeasapractitioner... care) that I’ve done everything that I can antenatally to Onemidwifeworkingwithanobstetricianinaprivatehos- get the best outcome at the birth because most of pital mentioned being restricted by his practice and beliefs in ... my clients are home birthers .SoIwantthem thewaysheadvisedwomenaboutnutrition.Shealsothought to be really healthy, really well nourished, really that she would be more forthcoming in discussing nutrition strong, prepared for labour, so everything goes as if she was working in the public sector. smoothly as possible. (Midwife 7, midwifery-led care/continuity of care) ...[the obstetrician] was popular...Ihadtobe mindfulofwhathefeltandthewayheworked Some midwives discussed customising their advice and and therefore I didn’t want to upset anybody messages according to their perceptions or assumptions of commenting on their weight or giving them advice the women they took care of. if it was unasked for....Soifsomebodyaskedme I think in that context of the birth centre generally or made a comment about being overweight, what women are well educated. It’s really just reinforc- canIdoaboutit,thenIwouldofferit,butIdidn’t ingwhatalotofwomenknow....(Midwife13, volunteer it. (Midwife 9, private practice for an group practice/birth centre/continuity of care) obstetrician/fragmented care) Midwives employed in public hospitals or the private sector A few participants presented their model of care as a holistic in traditional fragmented models of care and not continuity model looking at the women “as a whole.” They expressed the Nursing Research and Practice 5 view that the health of the women is affected by many factors, It was generated from Better Health; Victoria and nutrition can affect the woman’s health and that of her has a Better Health channel which gave a good baby and family in many ways during and beyond pregnancy. overview. (Midwife 1) In comparison to other health professionals such as doctors and dietitians, one midwife thought that midwives generally There was more focus on certain aspects of nutrition during focusedmoreonnutritioneducationcomparedtodoctors, pregnancy, especially those related to biomedical knowledge while another acknowledged that her technical knowledge is and blood tests when suspecting a deficiency or managing an limitedcomparedtoadietitianbutthissuitedthelowlevelof issue. This approach was in contrast to midwives’ perception literacy of the women she worked with. oftheirroleinprovidingnutritionadviceashealthpromoters and followers of a holistic approach. ... Ithink,insomeways,thefactthatIdon’thave ... a lot of the really technical scientific knowledge Isupposethemainonewasinthebirthcentre around nutrition maybe doesn’t actually matter contextthatwetendtohavemorediscussion that much in the sense that for many of my over is anaemia. So the influence is the woman’s clients their own...literacy skills can be quite iron is staying down low, of course you’ve got the limited and their language skills can be quite lim- potential for either being affected if, you know, ited. So actually keeping things really, really suc- they have a normal blood loss or the risk of cinct and simple is quite important in providing you know, postpartum haemorrhage, recovery, meaningful education...(Midwife 4, community- long term breastfeeding, you know, so we talk in based/continuity of care model) thosecontextsifwefindthatsomeone’sironis down low...The other dietary aspects, so within All midwives agreed on the importance of nutrition during the anaemia realm you know, you’re looking at pregnancy and were generally aware that it has impacts on the women who maybe are vegetarian so making sure health of the mother and the baby. However, not all midwives women have a very well rounded base with a could name specific pregnancy outcomes affected by nutri- vegetarian and supplements, so all of those things. tion behaviour and food selection of pregnant women. (Midwife 13) Some midwives viewed nutrition as the “first medicine,” so they tended to favour food over supplements when Some midwives had an active and individualised approach to discussing nutrition issues with pregnant women, especially discussing nutrition with the women, where they provided as it was believed that women were commonly more receptive verbal advice and did not merely depend on written infor- of nutrition messages while pregnant. mation. These midwives reported they discussed the woman’s diet and provided advice accordingly. So in terms of just women in pregnancy I think While some midwives focused on certain nutrition our team’s attitude was that nutrition should be aspects relevant to the women they provided care for (e.g., the first medicine....Sothenifyou’relookingat alcohol), others reported they abstained from discussing say a woman who has low-ish iron stores at the some aspects of nutrition (e.g., listeria and folic acid, or beginningofpregnancythenwe’relookingatfoods reducing consumption of caffeinated drinks and junk food). to increase her iron source...we’re also looking at Thiswasbasedontheirassumptionsofwomen’sprior micronutrients in food as opposed to going to the knowledge of the topic. Midwives made assumptions about chemist and buying a tablet. (Midwife 1) a woman’s status and attitudes (i.e., perceiving the woman to be motivated, well, or educated). Also, as a result of late Poor nutrition during nutrition was believed to be linked professional encounters with the women, midwives reported to outcomes such as preterm birth, large babies, postpar- assuming they were already informed (either the woman had tum haemorrhage, overweight, obesity, neural tube defects, sought information themselves or had received information anaemia, gestational diabetes, limited choice of model of care, earlier from other health professionals). miscarriage or stillbirth due to listeria, and for the baby to In terms of weight issues, not all midwives mentioned be prone to chronic diseases later in life. Good nutrition on discussing weight with the women, and some among those the other hand was linked to better health for the mother who reported doing so did not address it in-depth or directly. and the baby, managing pregnancy outcomes, and preventing Among the reasons mentioned was avoidance of causing complications such as gestational diabetes. worry to the women and trying to minimise the guilt around Nutrition was not routinely discussed, especially in a weight gain. comprehensive manner. All midwives discussed nutrition issues on some level; however, on closer examination many ...IguessItryandminimisetheguiltfactorin midwives used generalised or passive approaches, where they how much weight they put on because there’s considered the provision of written information sufficient, such a wide range and as long as they’re healthy. especially in terms of healthy eating advice for women they (Midwife 2) perceivedorassumedtobehealthywomen. Some midwives indicated that if they had more time, knowl- So in terms of information about nutrition on edge, and resources, they would like to focus more on their booking, we would give women information promoting healthy eating in general and specific aspects about nutrition on booking, a written pamphlet. related to pregnancy (e.g., obesity and diet for women from 6 Nursing Research and Practice different cultural backgrounds). They indicated they believed wholelistoffoodstobeavoidedandthenthat that providing adequate support to women to improve their sort of...went off the radar a bit and then it’s come health was important as pregnancy is a great time to do so. back in again...it’s very limited, extremely limited. (Midwife 8) 3.4. Preparation to Provide Nutrition Advice. Half of the Midwives considered self-directed learning (SDL) an essen- midwives believed that the coverage of nutrition during tial part of their job and it was their responsibility to update pregnancy within their midwifery education was nonexistent their nutrition knowledge and practice. However, it was or limited. If they recalled having received such pregnancy commenteduponthatlackofmandatoryeducationmight nutrition education, they remembered it as being mainly haveledtomorerelianceonself-directedlearning.Thiswas focusedonbasicsandlackingvariation.Someofthose problematic as it was believed that midwives would need to be midwivesindicatedthattheygainedmostoftheirknowledge highly motivated, interested, or working mostly in antenatal through work experience and communicating with other care to seek continuing education in nutrition. health professionals such as dietitians, a process which was ...as a midwife in Australia, I don’t know that a perceivedtobemoredifficultthanbeingtaughtinaformal ... manner. lot of time is given to nutrition in pregnancy Some midwives reported receiving nutrition education it’s behoven on the midwife to go get and find during their initial education, either in nursing or midwifery more information, to find resources to support education. However, nutrition education was perceived as informationtogivewomen.(Midwife1) like any other area where learning is life-long and it needed One midwife highlighted that continuing nutrition education continuing education. should be a shared responsibility between midwives and their employers. ...I mean I’ve been a midwife for a long time and I also did general nursing first. So...in my I think it’s the responsibility of both the employer general nursing there was fairly good, ...education and the midwife herself to make sure that they’re on nutrition but it’s a long time ago. And then up to date with the knowledge that they need for it’s really just what I’ve read...and I think I’ve their practice and...to keep abreast of...research got knowledge gaps as well, so...Ithinkallmid- that’s coming out and changes in guidelines and wives should have ongoing education in nutrition those sorts of things. (Midwife 4) because,...things change and we learn new infor- ... When asked what guidelines or sources of information are mation and that’s not necessarily, spread to the available for midwives to provide nutrition advice, most people working in the work place. (Midwife 10) midwives referred to written information they usually pro- Most of the midwives in this study were of mature age vided to pregnant women. Half the participants relied on and some mentioned being trained through hospitals. Many guidelines and/or government resources (e.g., brochures, acknowledged that they were not aware of the nutrition booklets, and websites) specific to the state or territory in educationprovidedinAustralianmidwiferycoursesoffered which they worked. A few referred to national sources such at universities but hoped that there is inclusion of current as the National Health and Medical Research Council dietary nutrition-related issues and specific issues such as food guidelines and ACM or international guidelines or resources intolerances and special diets. However, one midwife who such as the National Institute for Health and Care Excellence was trained through hospitals had also done a Bachelor guidelines. of Midwifery in the university system. She undertook a Midwives lacked awareness of any guidelines or specific designatedunitonnutritionbutreportedithadfocusedmore resources available especially for midwives to guide them onbreastfeedingthanonmaternalnutrition. in providing nutrition advice to pregnant women, with one There was a general view that Australian midwives do midwife suggesting that academics should develop such not receive adequate formal nutrition continuing education guidelines or resources. or support while practising, perceiving this as a reflection ...as far as I know there’s not actually any of nutrition being a neglected area. Midwives especially guidelines to guide midwives along nutri- remarked that there was a lack of continuing education activ- tion....Certainlynotinthemidwiferyguidelines. ities or opportunities for education about nutrition during There’s a vague mention of it in one of the pregnancy in the broad sense. Nutrition issues were reported elements in the midwifery practice guidelines but to be threaded into other issues rather than presented it’s vague and not specific about how to teach or separately at conferences or during in-service education. The how to educate or how to get your information or focus of the limited education that is available was perceived anything else.... It’s just saying that you should to be in relation to particular groups or issues (such as give good nutritional advice. (Midwife 12) obesity), reflecting issues with a high public focus. The reliability, validity, and layout of sources of information ...in recent years, with the obesity issue it’s come used seemed important to midwives, especially when using back into the focus a whole lot more now. I online and nongovernmental resources. Midwives com- mean there was a big focus a few years ago with mented that availability of the resources does not guarantee listeria...there was a big push on...providing a that midwives or women would access them. Nursing Research and Practice 7

Other sources of nutrition information were also men- Midwivespointedoutthatlackofrelevantandreliable tioned by the participants, such as talking with dietitians, nutrition education resources (such as handouts and web journal articles, resources provided by hospitals (e.g., hand- sites to refer women to or for the midwives to resource outs, and databases) or provided to hospitals in commercial accurate information or continuing education from) may packages (e.g., Bounty bag), and midwives’ experiences. hinder their role in the provision of effective nutrition advice Some midwives highlighted issues or problems with such to pregnant women. This was particularly highlighted by guidelines and resources; for example, the written resources midwives working with women from diverse linguistic and were often focused on food hazards more than health promo- cultural backgrounds. tion and polices were slow to respond to change. ...it’s not just because I work with Aboriginal women. I think it’s working with women from 3.5. Barriers Midwives Encounter in the Provision of Nutri- culturally and linguistically diverse backgrounds, tion Advice. The majority of the midwives, especially those is that the actual resources that we have are involved in fragmented models of care, defined time con- very...targeted at middle class Caucasian women straints as one of the major barriers affecting their activities that have reasonable literacy skills....Andthat’s, when it came to providing nutrition advice. Midwives in having resources that aren’t sort of targeted at continuity of care models also commented on time con- a broader range group I think is part of the straints. From their perspective, midwives saw the public challenge...That would be from sort of a systems health system as providing limited time to engage with point of view. (Midwife 4) pregnant women in regard to nutrition, with some comparing their current privileged situation with previous experience in Lack of nutrition knowledge was signalled by some midwives fragmented care. as a challenge to providing meaningful nutrition advice, Midwives commented that discussing nutrition took especially lack of knowledge of other cultures’ food choices. place usually at the booking visit, where the length of the ...we get a lot of Asian women and African visit was disproportional to the amount of work the midwife women in our community because...we have had to do and the amount of information the midwife had to refugees that are relocated in our area. They actu- convey to the women. ally struggle quite a lot. Well, we don’t understand their culture anyway.... So their foods, because Well, I think time, if you work in a busy public ... hospital, time’s the number one...they have to they are quite different to ours I’m not sure dosomuch.Like,forinstance,inabooking how we would manage, cross that sort of cultural interview...,atourhospital,whenyouseea barrier. So certainly there’s that barrier. (Midwife womanforthefirsttimeit’sanhourandahalf 12) interview and in that hour and a half you have to On the other hand, one midwife indicated that midwives are do so much, you’ve got to do their mental, physi- challenged by other sources of nutrition information, their cal, social history, psycho-social history, domestic reliability, and whether the mother trusts the midwives or violence screen, so many different things, and to those resources. throw nutrition into there, it’s important but it’s easily missed because of...all the paperwork, the ... As a midwife you’re competing with other documentation you have to do....(Midwife14) sources of information and you don’t know whether they’re valid or...you don’t know how One midwife highlighted that lack of time in public hospitals reliable they are and you also don’t know was not only an obstacle to provide the information to the where...the woman’s choosing to put her trust... women but also an obstacle for the midwife to update their who she’s going to...rely on. (Midwife 5) knowledge, allocate resources, and access experts who can provide such resources. This in turn can lead to a passive Other constraints related to the health system identified approach when conveying nutrition information. bythemidwivesincludedthemodelofcare(aspreviously described) and late encounter with pregnant women. ... in the public system everything is tightening up ... I think the restrictions are the fact that we a lot. So time restricts you not only giving your don’t see them ‘til later in the pregnancy...Not ‘til patient care and having time for the education about 13 weeks...well diet’s important the whole but it’s also time for updating your practice, find- way through but...that first trimester’s already ing out new information, finding the brochures, gone....Andyousortofwonderhowthey’vebeen accessing the dietitians and the people within the eating that whole time...by the end of the first health system, the Allied Health people that could trimester that baby’s fully formed and just needs provide that information for you. So very much togrowsoit’ssoimportantwhattheyeatbutwe you tend to fob people off and sort of say, well don’t get hold of them until after that. (Midwife 3) you’ll need to go and find that from there or you’ll say well do an Internet search, you’ll probably find Many midwives commented that provision of the nutrition that information there. (Midwife 12) advice would be variable as it would be subject to midwives’ 8 Nursing Research and Practice attitudes, such as their interest in nutrition (or lack thereof), The other challenge we have is the grand- and their perception of its importance, and even their ability mothers...And they’re going...IatewhateverIfelt to be an appropriate role model. like and you were fine so what’s the problem?... (Midwife 2) The problem is...if people are going to be dis- cussing nutrition with mums, there needs to be an 3.6. Facilitators That Would Help Midwives Provide Better intrinsic interest there...I’m really disappointed Nutrition Advice. Midwives repeatedly commented that con- when I see midwives with higher BMIs [Body Mass tinuing education about nutrition issues or regular updates Index] trying to give out dietary advice, so really on the latest evidence-based nutrition information would be that midwife can’t take it herself so how can she be helpful for them to provide quality nutrition advice. However, passing it on? (Midwife 11) they also stressed that continuing education or updates need Approximately one in three of the midwives pointed out to be provided by reliable sources such as the ACM and health women’s knowledge and attitudes as barriers to the provision services, as that would spare their time in navigating the of effective nutrition advice. “Lack of knowledge” referred abundant sources of information available. Online learning to foundational knowledge provided by subjects taught in basic modules or courses and in-service education were secondary education and lack of food-related skills (i.e., frequently mentioned. how to make healthy choices, shop, budget, and prepare Acommonstrategysuggestedbythemidwiveswas a meal). Attitudes included lack of motivation to change collaboration with allied health professionals, especially dieti- dietary behaviour, lack of emphasis on diet compared to tians as they were perceived as the “experts” who had the other issues (e.g., birth), body image (positive or negative), training and the knowledge. Collaboration with the dietitians noncompliance (e.g., with gestational diabetes diet), guilty andotheralternativeoralliedhealthprofessionals(e.g., feelings, or fear of harming the baby. naturopaths and physiotherapists) took many forms. For Social determinants of health for the women, such as example, some midwives suggested that dietitians should socioeconomic status, environment (i.e., access to healthy be involved in developing useful resources such as hand- and affordable food, and access to allied health care services outs, DVDs, and websites that the midwives can then use in remote areas), language and literacy, and culture were to enhance their practice or reinforce the messages they also barriers mentioned by the midwives as obstacles to the provided to pregnant women. provision of effective nutrition advice to pregnant women. Other participants proposed that dietitians educate the midwives and the midwives can then pass this education to The other thing is I think as midwives we are very pregnant women. It was suggested that dietitians need to conscious that sometimes the women that we’re be involved in maternity care by participating not only in dealing with come from difficult circumstances so, antenatal classes (as it was indicated this might be late or may you know, buying fresh fruit and vegetables might notcaptureallwomen)butalsoinantenatalappointments. be difficult or cooking in your facility might be dif- One midwife even suggested the need for a permanent ficult, so you tend to opt for the easiest option and position for a dietitian in antenatal clinics, as regular hospital that often isn’t the best in terms of nutrition.... dietitians would not see pregnant women unless they had That’s where... the social determinants of health complex issues. This suggestion was based on her experience affect a midwife’s ability to engage with a woman of having a temporary dietitian in her work place and in regards to her nutrition....(Midwife1) how that was beneficial not only for pregnant women (who may need quick personal chats) but also for midwives who It was identified by a midwife that it is quite challenging to used talking with the dietitian as a source for up-to-date explain the concept of risk to women with lower education information. Having back-up dietitians in the community for status as it may affect their reaction to the advice provided. pregnant women in the private sector was also recommended. ...we do talk about the concept of risk ....But However, it was realised that involving dietitians is a system many women have no antenatal care, do drink issue that might involve time and cost. throughout their pregnancy, do smoke, baby’s not ...thereshouldbetheabilityformidwivestobe breastfed, baby’s put straight onto the bottle and in collaboration with dietitians or nutritionists...I that baby will still chart nicely along a growth know that’s time consuming and I know that chart,willstilldoOKatschool,willstillbe it’s often hard to negotiate that and... [it] costs born and look normal and be of a good weight money, however, I think that would be the best way and so that’s a really difficult, I think that’s to do it. (Midwife 12) achallenge...Because the concept of risk is so abstract.... I think the expectations we have of Another strategy to help in preparing midwifery students to clientstoreallyunderstandthatis,attimesmight provide better nutrition advice suggested by the participants be a little bit unrealistic....(Midwife4) was incorporating nutrition into midwifery education. Mid- wives also suggested specific attributes for this incorporation, Midwives also referred to women’s family and work commit- including as an in-depth compulsory designated unit in all ments or incorrect advice from relatives as hurdles affecting midwifery programmes; in a broad way involving varied their provision of nutrition advice. health professionals such as dietitians and naturopaths; and Nursing Research and Practice 9 in a practical manner that meets the needs of practice in the midwives have an overreliance on written information and real world. adopt mostly a passive approach when advising pregnant Midwives also recommended other strategies related to women about listeria. the provision of nutrition advice in the antenatal care context Midwives’ advice in this study was on many accounts in general. This included better funding; standardisation of medically directed or provided when suspecting a deficiency information; availability of resources that meet the needs of or managing an issue. These results further confirm the young women, such as special applications and web sites quantitative findings of this cohort [12] and concur with inter- to enable early dissemination of nutrition information; and national research that has reported pregnant women received taking on a preventive approach rather than a management nutrition advice from midwives only when there were health one. Other facilitating strategies included the availability of issues or concerns [19]. Some midwives in this study refrained literacy appropriate resources; increasing the awareness of from or adopted a passive approach in discussing certain guidelines; and doing more research to improve nutrition topics with pregnant women when they perceived them to education provided to pregnant women. A few midwives be motivated and educated. While such an approach may be proposed that more time needed to be allocated to antenatal considered to have merit, it is not based on evidence. Bookari visits, so midwives could provide meaningful nutrition edu- etal.[20]foundthatasampleofmostlyhighlyeducatedand cation. motivated Australian pregnant women had poor nutrition knowledge and dietary behaviour and suggested health care ... Well, more time at the end of the day if the providers should not base their provision of nutrition advice midwivesdon’thavetimetotalktowomenabout to those women on such assumptions. nutrition, I guess there’s no point them resourcing The midwives’ accounts of the barriers and the challenges ... the information (Midwife 7) that restrict the midwife’s role in providing effective nutrition advice could be considered to be related to the health system 4. Discussion or otherwise out of their control, citing issues such as lack of time, lack of resources, limited basic and continuing nutrition This qualitative study explored Australian midwives’ percep- education, and the effect of their model of care. These results tions of their role in providing nutrition advice, the effect are in line with earlier literature where insufficient time, of their model of care on this role, and what facilitated or resources, and education were considered the main obstacles hindered it. Midwives believed that they have a vital role that impeded health care providers from educating pregnant in providing nutrition advice to pregnant women gener- women about nutrition [8]. ally in the context of health promotion; however, this was The midwifery philosophy is centred on building a rela- not reflected in the advice many of them provided. The tionship with the women and supporting and empowering advice seemed in many accounts passive and more medically them to make informed decisions that will improve their directed. Despite midwives’ beliefs in their role in this area, health and ultimately the health of the society [21]. This the extent and efficacy of this role appeared to be challenged relationship forms the basis for establishing rapport, trust, by many barriers. Midwives suggested some facilitators that respect, and confidence with the women which were the pil- mayhelpovercomethesechallenges. lars of effective nutrition communication according to most The perception of midwives in this study was that pro- midwives in this study. This was especially highlighted by the viding nutrition advice to pregnant women was a vital part remarks of most midwives providing continuity of care. Lack of their role. This is consistent with previous international of time to establish a relationship was frequently referred to as literature and the quantitative results of the cohort from a barrier by the midwives (mostly in fragmented care) to their whichthissamplewasrecruited[12,16],especiallyinregard engaging with pregnant women in discussing nutrition issues, to providing holistic nutrition advice in the context of health especially sensitive topics such as weight gain and obesity, promotion [10]. Our findings also support the argument of which is consistent with previous studies [22]. Motivational Cheyney and Moreno-Black [17] that midwives view food interviewing has been suggested as an effective strategy that and nutrition as an integral part of the holistic care that can be used by midwives when approaching women with underpins their midwifery model of care and as a means regard to sensitive issues such as obesity or to overcome to maintain health and wellbeing. Similarly midwives in barriers related to the women, such as their attitudes, for this study referred to viewing and using food as the “first example [23]. Several participants also suggested nutrition medicine” and as part of the holistic care they provided to or health promotion approaches may be effective but there pregnant women. was little indication that they were informed about what such Despite midwives’ belief in their role in providing general approaches may involve or whether they had the necessary nutrition advice in the context of health promotion, this was skill set for such an approach. not reflected in the generalised or passive approach many Midwives suggested a number of facilitators to overcome midwives in this study utilised in the way they conveyed the barriers that challenged their role in providing nutrition nutrition information to pregnant women. They expressed advice. Midwives requested continuing education in general a tendency to rely on written information as a means for nutrition. This may reflect their perceptions of the advice providing advice, particularly for women perceived and they needed to provide as “general.” They requested more assumedtobehealthy.Thesefindingsreflectthefinding educationfromreliablesourcestofeelsupportedandto of Bondarianzadeh et al. [18] who found that Australian reduce the overreliance on SDL that was perceived to be 10 Nursing Research and Practice dependent on time availability and midwives’ interest. They time for antenatal visits; encouraging continuity of care for all also requested collaboration with health professionals they women; creating permanent positions for dietitians in ante- considered the “experts.” While such continuing education natal clinics; and developing free online nutrition models and may be helpful in relation to the nutrition content, midwives training packages for practising midwives by the professional didnotidentifytheneedforin-serviceeducationinrelation organisations. A collaborative approach between midwifery to the skills necessary to promote nutrition to pregnant bodies, nutrition, and education experts and maternity care women or support their attempts to change their diets. services should be considered to implement such changes. Midwives in this study commented that they mainly While this study was confined to Australia, the findings relied on state-specific guidelines to guide their practice and recommendations have relevance to other countries that in providing nutrition advice but highlighted an absence support midwifery services. of midwifery guidelines. National clinical guidelines have been developed in Australia since this study was undertaken Conflicts of Interest [24, 25]. These guidelines specify that antenatal health care providers, including midwives, need to discuss nutrition at The authors declare that there are no conflicts of interest every antenatal opportunity by highlighting its importance, regarding the publication of this paper. assessing maternal diets, and providing advice in a holistic approach considering social determinants of health and referral to dietitians where appropriate. However, a recent Acknowledgments Australian study examining women’s perceptions of antenatal Jamila Arrish was a recipient of a doctoral scholarship from care provided to them against those guidelines found weight the Libyan government which partly supported this research. gain and diet to be the areas raised the least [26]. Midwives However, the Libyan government did not interfere with any wouldneedsupportonmanylevelsiftheyaretodiscuss part of the research. This research has also been conducted nutrition in an individualised and holistic approach, as spec- with the support of the Australian Government Research ified by the current clinical guidelines. Intervention studies Training Program Scholarship. The authors express their are needed to ascertain the best strategies to help midwives appreciation for all participating midwives for their valuable and other health care providers incorporate nutrition advice contribution to this project. The authors would also like to effectively into their practice and overcome common barriers. thank Ms. Cheryl Jecht for her assistance in transcribing the interviews and Ms. Elaine Newby for her assistance in editing 4.1. Limitations and Strengths. The nature of qualitative the manuscript of this paper. research limits its generalisability; however, this qualitative study enabled more understanding of midwives’ perceptions of their role in advising women about nutrition and the chal- References lenges that restricted this role. Even though only 16 midwives [1] P. S. W. Davies, J. Funder, D. J. Palmer et al., “Early life participated,theywerefrombothpublicandprivatesectors nutrition and the opportunity to influence long-term health: an and were engaged in various models of care. Saturation of Australasian perspective,” Journal of Developmental Origins of data was reached at 16 interviews as no new ideas emerged. Health and Disease,vol.7,no.5,pp.440–448,2016. The majority of the participants were of mature age with [2] A.L.Brantsæter,M.Haugen,R.Myhreetal.,“Dietmatters,par- less representation from younger midwives, reflecting the age ticularly in pregnancy-results from MoBa studies of maternal profile of the midwifery workforce in 2012 [27]. diet and pregnancy outcomes,” Norsk Epidemiologi,vol.24,no. 1-2, pp. 63–77, 2014. 4.2. Future Research. Future research needs to involve inter- [3] E. R. Fowles and S. L. Fowles, “Healthy eating during pregnancy: viewing younger or newly graduated midwives to explore determinants and supportive strategies,” Journal of Community their perceptions of their role in providing nutrition advice Health Nursing,vol.25,no.3,pp.138–152,2008. during pregnancy and their views of their educational prepa- [4] E. M. Szwajcer, G. J. Hiddink, M. A. Koelen, and C. M. J. van rations to provide such advice to cite any differences in this Woerkum, “Nutrition-related information-seeking behaviours regard from the views of mature midwives interviewed in this before and throughout the course of pregnancy: consequences for nutrition communication,” European Journal of Clinical study. Nutrition, vol. 59, no. 1, pp. S57–S65, 2005. [5] S. Thangaratinam, E. Rogozinska,´ K. Jolly et al., “Effects of 5. Conclusion interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence,” BMJ Journal, Although midwives in this study perceived providing nutri- vol. 344, Article ID e2088, 2012. tion advice to pregnant women as an integral part of their [6]J.M.Dodd,C.Cramp,Z.Suietal.,“Theeffectsofantenatal practice as midwives, this role was felt to be constrained dietary and lifestyle advice for women who are overweight by many challenges and factors mostly out of the midwives’ or obese on maternal diet and physical activity: the LIMIT control. Midwives need structured assistance, support, and randomised trial,” BMC Medicine,vol.12,no.1,articleno.161, guidance to provide holistic nutrition advice that assists 2014. women to achieve healthy pregnancies. Changes in the policy [7] S. J. De Jersey, J. M. Nicholson, L. K. Callaway, and L. A. of health care services were suggested such as allowing more Daniels, “An observational study of nutrition and physical Nursing Research and Practice 11

activity behaviours, knowledge, and advice in pregnancy,” BMC Government Department of Health and Aging: Canberra, 2014, Pregnancy and Childbirth,vol.13,no.1,article115,2013. http://www.health.gov.au/antenata. [8]C.Lucas,K.E.Charlton,andH.Yeatman,“Nutritionadvice [26] A. Waller, J. Bryant, E. Cameron, M. Galal, J. Quay, and R. during pregnancy: do women receive it and can health profes- Sanson-Fisher, “Women’s perceptions of antenatal care: are we sionals provide it?” Maternal and Child Health Journal,vol.18, following guideline recommended care?” BMC Pregnancy and no. 10, pp. 2465–2478, 2014. Childbirth,vol.16,no.1,articleno.191,2016. [9] A. Beldon and S. Crozier, “Health promotion in pregnancy: [27] Australian Institute of Health and Welfare, Nursing And Mid- theroleofthemidwife,”Journal of The Royal Society for the wifery Workforce 2012,AustralianInstituteofHealthandWel- Promotion of Health,vol.125,no.5,pp.216–220,2005. fare, Canberra, Australia, 2013. [10] D. J. Lee, C. L. Haynes, and D. Garrod, “Exploring the midwife’s role in health promotion practice,” British Journal of Midwifery, vol.20,no.3,pp.178–186,2012. [11] A. L. Wennberg, K. Hamberg, and A.˚ Hornsten,¨ “Midwives’ strategies in challenging dietary and weight counselling situa- tions,” Sexual and Reproductive Healthcare,vol.5,no.3,pp.107– 112, 2014. [12] J.Arrish,H.Yeatman,andM.Williamson,“Australianmidwives and provision of nutrition education during pregnancy: a cross sectional survey of nutrition knowledge, attitudes, and confidence,” Women and Birth,vol.29,no.5,pp.455–464,2016. [13]M.A.Neergaard,F.Olesen,R.S.Andersen,andJ.Sondergaard, “Qualitative description—the poor cousin of health research?” BMC Medical Research Methodology,vol.9,no.1,article52, 2009. [14] Z. O’Leary, The Essential Guide to Doing Research,Sage,London, 2004. [15] V.Braun and V.Clarke, “Using thematic analysis in psychology,” Qualitative Research in Psychology,vol.3,no.2,pp.77–101,2006. [16] S. Elias and T. Green, “Nutrition knowledge and attitudes of New Zealand registered midwives,” Nutrition and Dietetics,vol. 64, no. 4, pp. 290–294, 2007. [17] M. Cheyney and G. Moreno-Black, “Nutritional counseling in midwifery and obstetric practice,” Ecology of Food and Nutrition,vol.49,no.1,pp.1–29,2010. [18] D. Bondarianzadeh, H. Yeatman, and D. Condon-Paoloni, “A qualitative study of the Australian midwives’ approaches to Listeria education as a food-related risk during pregnancy,” Midwifery, vol. 27, no. 2, pp. 221–228, 2011. [19] A. L. Wennberg, A. Lundqvist, U. Hogberg,¨ H. Sandstrom,¨ and K. Hamberg, “Women’s experiences of dietary advice and dietary changes during pregnancy,” Midwifery,vol.29,no.9,pp. 1027–1034, 2013. [20] K. Bookari, H. Yeatman, and M. Williamson, “Falling short of dietary guidelines-what do Australian pregnant women really know? a cross sectional study,” Women and Birth,vol.30,no.1, pp. 9–17, 2017. [21] ACM, “Philosophy for Midwifery,” https://www.midwives.org .au/midwifery-philosophy. [22] D. L. Davis, J. E. Raymond, V. Clements et al., “Addressing obesity in pregnancy: the design and feasibility of an innovative intervention in NSW, Australia,” Women and Birth,vol.25,no. 4, pp. 174–180, 2012. [23] J. Raymond and V. Clements, “Motivational interviewing for midwives: creating “enabling” conversations with women,” MIDIRS Midwifery Digest,vol.23,no.4,pp.435–440,2013. [24] Australian Health Ministers’ Advisory Council, Clinical Prac- tice Guidelines: Antenatal Care–Module 1, 2012, Australian Government Department of Health and Aging: Canberra, http://www.health.gov.au/antenatal. [25] Australian Health Ministers’ Advisory Council, Clinical Prac- tice Guidelines: Antenatal Care–Module 2, 2014, Australian Gastroenterology International Journal of The Scientific Nursing Research and Practice Hypertension World Journal Research and Practice Scientifica Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Evidence-Based International Journal of Complementary and Breast Cancer Alternative Medicine Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

International Journal of Pediatrics Submit your manuscripts at https://www.hindawi.com

International Journal of Inflammation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Advances in

Current Gerontology Urology & Geriatrics Research

International Journal of International Journal of BioMed Endocrinology Surgical Oncology Research International Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com

International Journal of Hepatology

Computational and Surgery Mathematical Methods Advances in Research and Practice Prostate Cancer in Medicine Hematology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Appendix E: The published article of nutrition education in midwifery programmes

Hindawi Publishing Corporation Journal of Biomedical Education Volume 2016, Article ID 9680430, 12 pages http://dx.doi.org/10.1155/2016/9680430

Research Article Nutrition Education in Australian Midwifery Programmes: A Mixed-Methods Study

Jamila Arrish,1 Heather Yeatman,1 and Moira Williamson2,3

1 School of Health and Society, Faculty of Social Sciences, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 2School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia 3School of Nursing and Midwifery, Higher Education Division, Central Queensland University, 90 Goodchap Street, Noosaville,QLD4566,Australia

Correspondence should be addressed to Jamila Arrish; [email protected]

Received 13 July 2016; Revised 15 October 2016; Accepted 15 November 2016

Academic Editor: Dragan Ilic

Copyright © 2016 Jamila Arrish et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Little research has explored how nutrition content in midwifery education prepares midwives to provide prenatal nutrition advice. This study examined the nature and extent of nutrition education provided in Australian midwifery programmes. A mixed-methods approach was used, incorporating an online survey and telephone interviews. The survey analysis included 23 course coordinators representing 24 of 50 accredited midwifery programmes in 2012. Overall, the coordinators considered nutrition in midwifery curricula and the midwife’s role as important. All programmes included nutrition content; however, eleven had only 5 to <10 hours allocated to nutrition, while two had a designated unit. Various topics were covered. Dietitians/other nutrition experts were rarely involved in teaching or reviewing the nutrition content. Interviews with seven coordinators revealed that nutrition education tended to be problem-oriented and at times based on various assumptions. Nutrition content was not informed by professional or theoretical models. The development of nutrition assessment skills or practical training for midwifery students in providing nutrition advice was lacking. As nutrition is essential for maternal and foetal health, nutrition education in midwifery programmes needs to be reviewed and minimum requirements should be included to improve midwives’ effectiveness in this area. This may require collaboration between nutrition experts and midwifery bodies.

1. Introduction Australian pregnant women have poor nutrition knowl- edge and behaviour despite being highly motivated and The importance of nutrition during pregnancy for mother confident in their ability to adopt a healthy diet [7]. The and offspring is supported by a growing body of evidence [1, midwife is considered a trusted source of information by 2]. Pregnant women often display nutrition information seek- pregnant women [8]. Australian midwives believe nutrition ing behaviour [3]. Information and advice about healthy eat- during pregnancy is important and they have a role in ing during pregnancy/breast-feeding and about weight man- providing nutrition advice to pregnant women [9]. However, agement are some of the topics specifically requested by preg- their nutrition knowledge has been found to be lacking and nant women [4]. Health professionals rate the provision of only half report receiving nutrition education within their nutrition advice during pregnancy as important/very impor- midwifery education or during practice [9]. Educational gaps tant [5]. However, the proportion of those professionals pro- on particular aspects related to maternal nutrition, obesity, viding advice across different nutrition topics is low (16–32%) and weight management were indicated in international and [5] and a majority of pregnant women do not receive appro- Australian research [10–14]. Attempts by two international priate nutrition advice from their health professionals [6]. universities to integrate nutrition within their curricula were 2 Journal of Biomedical Education briefly reported [15, 16]. There is a paucity of research about given the same priority) and the results of both data are nutrition education provided in midwifery programmes. merged in the overall interpretation [22]. The main purpose In Australia, midwifery education is offered through of this design is to obtain a comprehensive understanding both undergraduate and postgraduate programmes. Mid- of the topic under study and to validate or corroborate the wifery education is overseen by the Australian Nursing results from one method with the results of the other [22]. and Midwifery Council (ANMC). The name of the coun- cil has changed to the Australian Nursing and Midwifery 2.2. Stage 1: The Survey Accreditation Council (ANMAC), reflecting its role as the independent accrediting authority which sets the standards 2.2.1. The Purpose. The purpose of the survey was to inves- of accreditation for midwifery programmes (with the latest tigate the extent and nature of nutrition education provided versionreleasedinOctober2014)[17,18].TheNursing in Australian midwifery undergraduate and postgraduate and Midwifery Board of Australia (NMBA), the regulatory programmes and the views of midwifery coordinators on the body of the nursing and midwifery professions in Australia, midwife’s role in nutrition education and the importance of approves the accredited programmes [17]. nutrition in midwifery curricula. Successfully completing a midwifery programme accred- ited under the ANMAC Midwife Accreditation Standards 2.2.2. Respondents and Survey Dissemination. The list (as enables graduates to apply for registration as a midwife in at 1 May 2012) of all Australian accredited midwifery pro- Australia [17]. The ANMAC published the first National grammes leading to professional registration as approved Competency Standards for the Midwife in 2006 following by the NMBA was obtained from their website. The list two years of research/development and validation, and they included 50 programmes comprising 23 undergraduate and undergo regular review and revision [17, 19]. These com- 27 postgraduate degrees from 29 universities, the name of petency standards include the core competencies used by the approved institution/provider, the qualification provided registration authorities, education providers, and employers (type of the programme, e.g., undergraduate or postgrad- to assess if a midwife is competent for registration and uate), the state or territory in which the programme was practice [17]. provided, and the period of accreditation. The previous Accreditation Standards [18] did not have Course coordinators were deemed the appropriate point any mention of nutrition [20]. The current ANMAC Mid- of contact, as the ANMC accreditation standards [18] did wife Accreditation Standards [17] have undergone minimal not have specific requirements for nutrition education within change in this regard. They emphasise that the curricula curricula,andthecoordinatorwouldhaveanoverview should be underpinned by “primary health care principles” of their programme content. The contact details of course which include “promotion of food supply and proper nutri- coordinators for the identified programmes were obtained tion” [17]. However, they do not stipulate any specific nutri- through searching of institutional websites and telephone tion education requirements to be included in the curricula. enquiry. The coordinators were contacted via email and The National Competency Standards for the Midwife specify invited to participate in the study and complete the online public health issues that need to be addressed by the midwife, survey. The invitation email had brief information about the such as “promotion of breast-feeding,” “smoking cessation,” study, its aims, and the researchers’ contact details. It also “domestic violence,” and “drugs or alcohol use” [19]. There is had a hyperlink to the online survey. Three reminders were no mention of nutrition or the promotion of healthy eating. sent to non-respondents at one month, three months, and According to the International Confederation of Midwives fourmonthsfromtheissueoftheinvitation.Surveyresponses (ICM) Essential Competencies for Basic Midwifery Practice were collected from June to December 2012. [21] (revised 2013), midwives should have “the knowledge and/or understanding of nutritional requirements of the 2.2.3. Survey Development and Structure. Only one survey pregnant woman and foetus” and “the skill and/or ability investigating nutrition education of midwifery programmes to assess maternal nutrition and its relationship to foetal was identified when the current study commenced [14] but it growth;giveappropriateadviceonnutritionalrequirements hadaslightlydifferentaimandwasbasedontheUnitedStates of pregnancy and how to achieve them” (pp. 8 & 9). It would of America’sspecific nutrition competencies. Therefore, it was be expected that midwives require adequate education to deemed not relevant to Australia for the purpose of this study. provide such advice. A short survey consisting of 10 items was developed. This study examined the nature and extent of nutrition Coordinators were asked to indicate the degree/s they were education provided in Australian midwifery programmes. coordinating, nominate the total number of hours allocated to nutrition in the curricula, nominate from a list of nutrition 2. Methodology topics those covered in their curricula (formulated from prior literature and government websites) [20, 23–25], indicate 2.1. Study Design. The study used a mixed-methods approach the professional qualifications of content providers, report and consisted of two components: an online survey and the frequency of content review, indicate the involvement semi-structured interviews. A convergence parallel design of experts in the review process and the qualifications of was utilised for the overall study. In this design, quantitative reviewers, and express their own views on the midwife’s and qualitative data are collected and analysed independently role in nutrition education during pregnancy, including the within the same time frame of the research process (ideally significance of this role and the importance of nutrition Journal of Biomedical Education 3 education in midwifery curricula and for the clinical practice The semi-structured interviews were conducted and of midwives. Respondents were asked to rank their agreement audio-recorded via the telephone by the lead author (JA) with survey items using five-point scales (e.g., “very impor- between November 2012 and March 2013. They lasted tant,” “moderately important,” “important,” “slightly impor- between11and26minuteswithanaveragetimeof15minutes. tant,” and “not at all important”). Space was provided for An interview guide was used as shown in the following respondents to supply any additional options or comments. Two experts (in public health nutrition and midwifery) (1) Can you please outline how food and nutrition issues and a dietitian reviewed the survey for content, readability, are presented within the midwifery curriculum at and relevance. As a pilot, the survey was then sent to five your institution? researchers and two course coordinators, one of whom was (a) What importance, if any, is placed on teaching a coordinator of a midwifery programme. Minor modifi- about nutrition during pregnancy compared to cations were undertaken based on their feedback. Survey- other topics in your programme? Monkey Software (SurveyMonkey Inc., Palo Alto, California, (b) Who is responsible for the nutrition compo- USA, https://www.surveymonkey.com) was used to make the nents in your programme? Can you please amended survey available online. outline any particular qualifications in nutrition held by these academics/guests? 2.2.4. Data Analysis. The Statistical Package for the Social Sciences (SPSS) Software version 22 (Armonk, NY: IBM (2) Can you please outline the development and review Corp.) was used for the analysis. Responses were reported activities linked with the nutrition curriculum within by frequency and percentage. Fisher’s exact test was used to your programme? examine the association between nutrition topics covered and programme type (i.e., undergraduate or postgraduate), and it (3) Please outline how nutrition curriculum within your wasalsousedtoexaminetheassociationbetweennutrition programme is informed by particular pedagogical or topics covered and seeking experts’ advice in reviewing professional theoretical models. theprogramme’snutritioncontent.Theassociationbetween (4) Are there any particular aspects of the curriculum hours allocated to nutrition and programme type was also that assist to prepare your graduates to provide examined. The answer of one coordinator who coordinated evidence-based nutrition information? bothundergraduateandpostgraduateprogrammesattheir institution was excluded in the comparison of nutrition (a) Any national standards that you follow? topics between undergraduate and postgraduate midwifery (b) Development of nutrition assessment skills? programmes as their answer to that question related to both (c) Practical training in nutrition? programmes and not one or the other. Statistical significance was set at alpha level of 0.05. (5) How well do you think graduate midwives from your Responses on hours allocated to nutrition were cate- programme are prepared to provide evidence-based gorized into four categories (<5 hours, 5 to <10 hours, 10 nutrition information for pregnant women? to <15 hours, and 15 hours or more). The four categories (a) Are there any particular barriers that may were combined into two categories (<10 hours or 10 hours impede them in this role? What facilitates their andmore)forthepurposeofstatisticalanalysisdueto practice in this role? small numbers in some categories. Responses to open-ended survey questions were categorised and described. (6) Do you have any other points that you would like to raise? 2.3.Stage2:TheInterviews The questions were reviewed by the co-authors, two experts 2.3.1. The Purpose. The purpose of the interviews was to (midwifery and public health), and a dietitian. One interview explore the coordinators’ perspectives on how nutrition was conducted with a midwifery course coordinator as a pilot. is incorporated within their programmes and deepen the understanding of the findings of the quantitative study. 2.3.3. Data Analysis. The interviews were transcribed verba- tim by a professional transcriber and checked for accuracy by 2.3.2. Data Collection. Qualitative description was the JA. Data analysis was facilitated by using QSR International’s approach chosen for this study [26]. Semi-structured NVivo 11 Software. The interviews were analysed thematically telephone interviews were used to collect the data. In the in a descriptive manner. The lead author read and reread email invitation to participate in the survey, a note about the transcripts to become immersed in the data. All the furthercontactatalater timeforaninterviewanditspurpose authors coded one transcript independently and another was included and the coordinators were asked to email the one as a group and discussed the coding. The lead author researcher if they were interested to participate in the inter- then coded the rest of the transcripts and discussed the views. Those who did were contacted at that time and inter- coding of all transcripts with one or both of the co-authors viewed. Further invitations to participate in the interviews until consensus was reached. The lead author organised the were emailed to the other coordinators in January 2013 and descriptive themes, finalised the analysis, and confirmed the a reminder to non-respondents was sent in February 2013. final results with the co-authors. 4 Journal of Biomedical Education

Table 1: Overview of the respondents and included programmes. 𝑛 of coordinators and 𝑛 of invited coordinators and programmes included in the accredited programmes in % study 2012 Respondents 23 41 56.1 Programmes 24 50 48.0 Undergraduate 14 23 60.9 Bachelor of Midwifery 11 Bachelor of Nursing/Bachelor of Midwifery 3 Postgraduate 10 27 37.0

2.4. Ethical Considerations. Ethicalapprovalwasreceived (𝑛=7)and8.7%(𝑛=2)) rating them as “very important” and from the University of Wollongong Health and Medical “slightly”/“not important,” respectively. Slightly over a third Human Research Ethics Committee (HE12/038). The coordi- (34.8%, 𝑛=8) rated nutrition in midwifery curriculum as nators indicated their consent in the survey by completing it “moderately important,” while 30.4% (𝑛=7)chosethesame and provided consent for the interviews either orally or in a rating for nutrition education during pregnancy for midwives written format. in clinical practice. The proportions that rated nutrition in midwifery curriculum and nutrition education for practising 3. Results midwives as “important” were 26.1% (𝑛=6)and30.4% (𝑛=7), respectively. 3.1. Stage 1. Forty-four identified coordinators from 50 pro- Sixteen coordinators representing 17 programmes pro- grammes (some coordinators coordinated more than one vided a discrete number of hours allocated to general nutri- programme) were sent the invitation; however, three coordi- tion and/or nutrition during pregnancy, while five provided nators were excluded based on failed delivery of invitation, an approximate range. Two coordinators did not provide a discontinuation of the programme, and duplicate invitations value or estimation. The number of hours spent in total on for one programme. Therefore, the final number of potential nutrition education during their programmes ranged from 2 respondents was 41. to 48 hours. Figure 1 illustrates the hours allocated to general A total of 25 responses were received but one was nutrition and/or nutrition during pregnancy in midwifery excluded from the analysis due to insufficient data. For curricula by programme type. Half of the programmes (11 of oneprogramme(BachelorofNursing/BachelorofMidwifery 22) had 5 to <10 hours of nutrition content (6 undergrad- (double degree)) the survey was completed by two respon- uate and 5 postgraduate programmes). Three coordinators dents (the overall coordinator of undergraduate degrees in reported that <5 hours were allocated to nutrition in their that school and the course coordinator of the double degree). programmes, and four reported 10 to <15 hours or 15 or more As the survey was intended to have only one response from hours of nutrition content. Only undergraduate programmes each programme, only the response from the coordinator of had 15 hours or more of nutrition content (𝑛=4). Two thedoubledegreewasincludedintheanalysis. programmes had designated nutrition units and these made Table 1 shows the number of respondents and the details up half of the programmes that had 15 hours or more (2 of 4). of programme type and frequency. The final response rate of Four respondents reported that, other than the stated the survey was 56.1% (23 of 41). One of the included survey hours, nutrition content was embedded within other subjects respondents coordinated both undergraduate and postgrad- and one respondent indicated that a new subject on nutrition uate programmes at their institutions, while the remaining respondents each represented a single programme. Twenty- was planned to be included in the curriculum. Reading/class four accredited programmes were included, representing exercises and academic assessments that included a nutrition 48% of the programmes originally listed on the NMBA list. focus were mentioned by two coordinators. Two other coor- To preserve anonymity, the respondents were not asked to dinators highlighted that students were likely to be exposed identify their university. to education on nutrition during clinical placement. No When asked if midwives had a professional role in significant association was found between hours allocated to educating pregnant women about nutrition, all except one of nutrition and programme type. thecoursecoordinatorsresponded“yes”(95.7%,𝑛=22). All of the respondents indicated that midwives were Of these course coordinators, the majority (63.6%, 𝑛=14) involved in providing the nutrition content of their pro- thought this role was “very significant,” 22.7% (𝑛=5)rated grammes. Five respondents indicated that dietitians or nutri- it as “moderately significant,” and 13.6% (𝑛=3)rateditas tionists were also involved in providing nutrition content. “significant.” Six respondents identified other health professionals (such The majority (91.3%, 21 of 23) of the respondents consid- as scientists, nurses, and lactation consultants) as involved in ered nutrition in midwifery curriculum and nutrition edu- providing nutrition content. cation during pregnancy for midwives in clinical practice to Table 2 shows the nutrition topics covered in the partic- beimportantonsomelevelwiththesameproportions(30.4% ipating midwifery programmes. Various topics of nutrition Journal of Biomedical Education 5

Table 2: Nutrition topics covered in participating midwifery programmes. (a) Topics Number % (1)Topicsofnutritionduringpregnancy Alcohol and pregnancy 23 100 Nutrition related issues such as managing nausea and vomiting 23 100 Nutrition during pregnancy, for example, the role of folate, iodine, or calcium 22 95.7 The healthy range of weight gain required for pregnant women 22 95.7 Nutrition for breastfeeding 21 91.3 Nutrition management of gestational diabetes 20 87.0 Food safety and preparation during pregnancy (e.g., listeria) 19 82.6 Managing weight during pregnancy 16 69.6 Nutrition assessment (e.g., reviewing diet for nutrition requirements of pregnancy) 15 65.2 Nutrition and teenage pregnancy 11 47.8 Nutrition during pregnancy and different cultural groups 10 43.5 (2)Topicsofgeneralnutrition General nutrition for special groups (e.g., vegetarians, vegans, and different cultural groups) 13 56.5 General nutrient information, for example, the role of nutrients, vitamins, and minerals in the body 12 52.2 General food safety 939.1 General nutrition, for example, prevention of chronic illnesses such as cancer or heart disease 6 26.1 (b) Other 313.0 (a) Multiple responses allowed. (b) Other included “obesity,” “eating disorders,” and “diets of heart and kidney diseases.”

100% 90% 80% 70% 60% 50% 40% Percentage 30% 20% 10% 0% <5 hours 5 to <10 10 to <15 15 hours or hours hours more

Postgraduate programmes 9.1% 22.7% 9.1% 0.0% Undergraduate programmes 4.5% 27.3% 9.1% 18.2%

Postgraduate programmes Undergraduate programmes Figure 1: Hours allocated to general nutrition and/or nutrition during pregnancy in midwifery curricula by programme type. during pregnancy were covered but there was less reported No significant association was found between nutrition coverage of important topics such as “managing weight topics covered and programme type (undergraduate or post- during pregnancy” (16 of 23) and “nutrition assessment (e.g., graduate) or between nutrition topics covered and seeking reviewing diet for nutrition requirements of pregnancy)” (15 experts’ advice to review programmes’ nutrition content. of 23), while topics such as “nutrition and teenage pregnancy” More than half (60.9%, 𝑛=14) of the coordinators (11 of 23) and “nutrition during pregnancy and different indicated that nutrition content of their programmes was cultural groups” (10 of 23) were the least covered topics. It was reviewed and updated on an annual basis, and, within the also noticed that the coverage of topics of nutrition during remaining programmes (39.1%, 𝑛=9), it was reviewed every pregnancy was reported more frequently in comparison to 5yearsaspartoftheaccreditationcycle.Threecoordinators the coverage of topics of general nutrition. commented that the curricula were reviewed each semester 6 Journal of Biomedical Education or each time a subject was presented. Three other respondents OK.Well,thereisnounitspecificallyaboutfood commented that the content was updated continually as new and nutrition in the midwifery course. Our course materials and evidence became available. One coordinator is a postgraduate diploma course and all of our stated “not specifically addressed—is embedded across sub- students are Registered Nurses, so I guess in one jects.” wayit’sassumedthattheycometothatcoursewith Nearly three-quarters (73.9%, 𝑛=17)ofthecoordina- quite a high degree of general knowledge about torsreportedthatthereviewofnutritioncontentoftheir health, so that’s, I guess, a bit of a background. programmes did not involve seeking input from experts ... they also learn about the antenatal care of a (either internal or external). Of those who identified input woman and so quite obviously that entails good from experts was sought (𝑛=6), two had consulted health and good diet and it also looks at things like a dietitian. A midwifery external advisory committee was listeria and, you know, foods that they shouldn’t reported by another coordinator as the experts involved in eat and the reasons behind that. (Coordinator reviewing nutrition curricula. The survey did not include Two-Postgraduate) a specific item on barriers to consulting experts (including dietitians) for the development, teaching, and/or review of All coordinators considered the nutrition content to be nutrition components of midwifery programmes; however, important on some level compared to other topics or units two respondents indicated that cost was a barrier. within their programmes. However, this was expressed in different ways. The coordinators who had designated units considered the nutrition units as important as other units. 3.2. Stage 2. Seven coordinators participated in the inter- They specified that presenting nutrition as a designated unit views; of these, four coordinated postgraduate midwifery was a reflection of the level of this importance. programmes and three coordinated undergraduate pro- grammes. Nutrition content was integrated in all postgrad- We ... identified when we were developing our uate programmes and in one undergraduate programme, curriculum, the importance of nutrition and the while the other two undergraduate programmes had desig- understanding of same for our students ...when natednutritionunits.Oneofthetwoprogrammeshaving working with women during pregnancy. So we a designated unit also had additional nutrition content actually have a whole unit, a 12 credit point integrated into other subjects. The designated unit for the unit, designated to nutrition in the midwifery pro- other programme was specified as compulsory by the course gramme. Alongside of this ...with our units that coordinator. cover normal pregnancy, birth, post-natal and Staged presentation of nutrition content was indicated high acuity, which is like very complex midwifery by the coordinators according to life stages related to preg- experiences, nutrition is dealt with at a unit level nancy (i.e., preconception, pregnancy, and breast-feeding), as well. (Coordinator Seven-Undergraduate) according to the level of midwifery care delivered to preg- Three coordinators considered nutrition to be very impor- nant women (i.e., normal, complex, and emergency), and/or tant. Two of those coordinators cited the integration of within topics such as anatomy and physiology. The focus in nutrition throughout the curricula as a reason, while one the content tended to be clinical or problem-oriented (i.e., highlighted that teaching about nutrition should be in the anaemia, malnutrition, obesity, and diabetes). context of woman-led care, where the student identifies and One coordinator who had integrated nutrition content discusses nutrition issues specific to that woman instead of pointed out that they did not have a separate topic/lecture getting taught about specific nutrition topics. for nutrition and it would come up in the discussion of other topics. This may imply that nutrition was not considered I think it’s very important, nutrition is very formally as part of the curriculum. important. But I think it’s very important that it’s woman-led and student-led rather than us stating Wecoveralittlebitofitwhenwe’retalking students learn this, this and this about nutrition. about anaemia in pregnancy....Yes....Ithink So we talk about the importance of when they’re that’s about it. And I might say that throughout discussing nutrition and food with a woman that theyearwewilldiscuss,youknow,thefoods the student finds out what’s important to the that women will have to avoid when they are woman rather than, you know, going through a pregnant ...especially the ones that causes listeria tick box thing that they’ve covered everything. ... thatsortofcomesupasageneraldiscussion (Coordinator Six-Postgraduate) during lectures....Itisnotaseparatesubject. (Coordinator Four-Postgraduate) One coordinator indicated that nutrition was of moderate importance, while another indicated equal importance with other topics but admitted that time allocated to nutrition Another coordinator made a few assumptions about how stu- content did not reflect this status. dents acquire nutrition knowledge. She assumed that nurses enrolling in midwifery programmes came with previous ...out of the whole 3 years it’s talked about in knowledge and that students would learn about nutrition Year 1, one lecture and two tutorials, that’s it.... when learning about antenatal care. That lets you know how important it is and if Journal of Biomedical Education 7

we don’t give it any more time than that the the ANMC [Australian Nursing and Midwifery students won’t see it as important. (Coordinator Council] Competencies Standards for the Regis- Five-Undergraduate) tered Midwife...they’re listed so that the student knows that’s what they’re supposed to be doing ... For programmes with integrated nutrition content, the and all that talks about in there, the closest one responsibility was fully that of the midwives (i.e., the coordi- thatwouldgoanywhere... relatedtonutrition nators or midwifery academics), with no or little involvement is competency 5, element 5.1 assess the health of experts in the field (such as dietitians). Nutritional exper- and well-being of the woman and baby. So there’s tise was not requested, not considered necessary, nor could it nothing really that underlines how we teach about be guaranteed. nutrition, it’s what we find in the textbooks or In programmes with designated nutrition units, one unit our midwifery readings and that’s it. (Coordinator was delivered by an academic who was also a dietitian; in Five-Undergraduate) the other, the expertise of the dietitian was acknowledged by involving them in teaching the unit. Dietitians as experts were Coordinators identified specific aspects of the nutrition called upon to deliver technical content that midwives were education within their programmes which would help their not comfortable or sufficiently skilled to deliver; however, students to provide nutrition advice to pregnant women. their skills in teaching counselling or how to talk to women Some of these aspects included the content itself, how the about nutrition were not fully used. materials were presented (designated or integrated), the ...what she [the dietitian] does is gives nature of the course (e.g., inquiry based), and the clinical the...science behind why nutrition is impor- placement including continuity of care. tant....the reason I get a dietitian is because they Most coordinators reported using governmental guid- have that in depth knowledge of understanding ance such as the National Health and Medical Research what happens at the cell level and so on whereas Council (NHMRC) dietary guidelines and reference values. as a midwife, I mean I understand it but I couldn’t However, in two instances, this was undertaken by just giving teachit.Icouldn’tanswerthequestionsifthey the brochures to the students. One coordinator reported were too curly for me, you know, whereas she can. that there was no teaching about dietary guidelines within (Coordinator Three-Undergraduate) their programme as students are registered nurses and were assumed to have previous knowledge. Another coordinator One coordinator assumed that diet is “straightforward” in assumed that a hospital dietitian would be the source of up to comparison to other issues. She also assumed that a pro- date information for the students. gramme would not pass accreditation unless it contained nutrition content. No. No. I wouldn’t say we [follow any national ...... standards] as I said, the dietitian at the hospital in most instances whatever the student is actually,wepresume,hasthemostuptodate researching, whether it is domestic violence information and that’s what will be discussed or whether... they’re looking at something as ...... with the women in any case we will sort of straightforward as diet (Coordinator Two- follow the lead of the dietitian but we ourselves, Postgraduate) Iwouldn’tsayweactuallygoseekingthatkindof Similarly, the curriculum development and review activities informationbecausewedon’tactuallyhaveatopic were midwifery driven and relied on the academic responsi- that looks at nutrition into detail. (Coordinator ble for the content to keep up with the literature. In designated Four-Postgraduate) nutrition units, one unit had a nutritionist as an assessor. The development and review activities were easier to identify and Overall, there was a lack of adoption of approaches that report. Two coordinators admitted nutrition content did not would specifically teach the students how to assess women’s get reviewed as it was integrated. One of these coordinators nutrition requirements or advise them about achieving such reflected that reviewing nutrition content and evaluating how requirements in the programmes included in the study. it is taught might be an idea worth considering in the future However, one coordinator indicated that their programme to assist in preparing students for their role in providing used “motivational interviewing” as a way of working with nutrition advice. women who have lifestyle issues (e.g., obesity or smoking). No coordinator reported professional or theoretical mod- Another one cited a class activity about altering a menu. els as informing their nutrition content, in contrast to the use Three coordinators mentioned that nutrition may be involved of such models to support breast-feeding (as was pointed out in some standard practices as part of caring for women by two coordinators). Some respondents were not aware of (e.g., practising booking a visit and case studies). Three any national midwifery support or guidance in relation to assumed students would develop those skills during clinical nutrition content. placement, although it was indicated that student exposure to nutrition education during clinical placement could not Well, no [professional or theoretical models to be guaranteed. There was a concern that any such exposure inform nutrition content]. I’ll tell you in the during placement would be generally problem-oriented and module, in our tutorials outline we always put in could be based on stereotyping. 8 Journal of Biomedical Education

...There’s also a part of the course where students not “dietitians,” while another one thought that the midwifery look after women in a continuous way called academics were professionals who kept themselves up to date continuity of care ... the student would speak to with the necessary information. the woman, would educate the woman in a very non-structured way in the form of really focused No [barriers], not really...we could get a dietitian care about her, so I feel that if the student was in to talk to the students but their contact time looking after a woman that was very well educated is limited and I think that the level of knowledge and very healthy and that had enough money to that the students need to impart to the pregnant buyfoodandthatwasinasecurerelationship women ... should be well enough covered by that ... [the student] probably wouldn’t spend a the experienced academics that teach them ... lotoftimetalkingtothemaboutgoodnutrition those academics ... alloftheinformationthat because they would probably be looking at that they teach, is informed by research ... it’s not woman and saying, this woman understands storytelling,sotheyarelookinginto... texts about good nutrition and it would be approached that are written and best evidence with published in a circumspect way. But if on the other hand papers in order to prepare the lectures that they they were looking after someone who had very give to students and the content that they provide. little money and who ...didn’t have support then (Coordinator Two-Postgraduate) ... theywouldtakeonthatrole,theywouldsee that as a much more important part of what One coordinator indicated that graduating midwives might they do, if that makes sense. (Coordinator Two- face barriers such as a poor model of care (i.e., the model Postgraduate) fails to allow sufficient time which leads to the provision All the coordinators thought that the graduates from their of problem-oriented nutrition advice). On the other hand, programmes would be generally prepared to provide nutri- another coordinator acknowledged that factors such as in- tion advice at a basic level to pregnant women. However, one service education sessions for midwives with dietitians could coordinator indicated that a deep understanding of the short- help practising midwives provide quality nutrition advice. and long-term effects of nutrition on the health of mother and Some coordinators commended the current research, offspring would be lacking. with one stating it highlighted the gaps in their curriculum Some coordinators believed that knowledge of principles and its clinical focus. such as consultation and referral and woman-centred care would be sufficient preparation for providing nutrition advice I think this [current research] is a good thing...to at a basic level to pregnant women. Only one programme go through and look at what my colleagues are had formally evaluated their nutrition unit. They obtained teaching our students because there are other positive feedback from their students. people who contacted me with similar kinds of studies on other various things in our curriculum I believe they’d be excellently prepared in that, and it really highlights when you do this, what is ... they would be following the principles of not in our curriculum. And I think curriculums woman-led care, they’d be following the principles are still basically focused on disease processes. So of consultation and referral, so if there was a even though midwives say we’re all about well woman with specific needs, most of the units and healthy and supporting women that’s not have a dietitian that they could refer to and what we’re spending our 3 years teaching students. ... seek advice from we are graduating midwives, (Coordinator Five-Undergraduate) woman-centred, evidence-based midwives, as far as consultation and referral goes that they would know when further expert advice was needed. 4. Discussion (Coordinator Six-Postgraduate) ThisstudyfoundthatAustralianmidwiferycoursecoordina- The coordinators provided mixed responses when asked tors considered nutrition education in midwifery curricula about barriers and facilitators within programmes that may and the role midwives can play in this area as important. hinder or help students to learn to provide nutrition advice. However, this was not reflected in the nutrition content of Some participants said that there were no barriers or they the programmes. Nutrition components were included in all were unable to identify specific barriers but then supplied in programmes represented by survey respondents but hours their description of facilitators an indication of their course allocatedtonutritionweregenerallylowandtopicscovered inadequacy; or they named specific barriers but then implied varied. Only two programmes had designated nutrition units. that they were “doing enough anyway.” Some identified Dietitians were not often involved in teaching nutrition and barriers included a lack of a separate nutrition topic (due to few programmes involved experts in the review of their lack of time), a lack of face to face interaction, and a lack nutrition curricula. The interviews revealed that nutrition of a dietitian’s involvement. Conversely, their opposites were education tended to be problem-oriented and at times based some of the facilitators. One coordinator mentioned that their on various assumptions. Nutrition content was not informed programme had no barriers as she believed midwives were by any professional or theoretical models. The development Journal of Biomedical Education 9 of nutrition assessment skills or practical training for mid- The tendency of the nutrition content to be focused on wifery students in the provision of nutrition advice was problems or medical issues may be attributed to the medi- lacking. calisation of pregnancy [32] and high prevalence of obesity The variable and few hours allocated to nutrition and and other pregnancy related complications [33], which may small numbers of programmes having designated units are have led to the change of midwifery from being a health comparable with findings from international research [13, and wellbeing promoting profession to a one being more 14]. In the United Kingdom’s midwifery programmes, hours focused on risk and disease management. In a survey of more allocated to “maternal nutrition” and “obesity/weight man- than 300 Australian midwives, around 60% indicated that agement” topics within public health curricula were fewer they provided nutrition advice only if the pregnant woman than 10 hours and these topics were mostly integrated into the hadamedicalissueand24%didthatonlyifthewoman curricula [13]. When nutrition is integrated across subjects, asked questions [9]. In the current study, the importance of it could be perceived as less important and therefore not nutrition being taught in the context of woman-led care was emphasised as it should be in practice [27]. It would also be referred to, as was the possibility of the medical or problem- more challenging to review coverage of core nutrition topics. oriented focus of nutrition education provided to students In contrast, its importance is highlighted when nutrition is during clinical placement and the probability of students presented as a designated unit, as was identified by some stereotyping women when providing nutrition advice (the coordinators in this study. From a practical perspective, last two somewhat problematic). According to the philosophy having nutrition as a stand-alone unit in all midwifery pro- of the Australian College of Midwives (ACM) [34], midwives grammes might not be feasible, particularly in postgraduate provide woman-centred care where they work in partnership programmes, where the length of the programme (from 12 with women and focus on women’s specific health needs, to 18 months) might be a challenge. With the challenge of a expectations, and aspirations. However, caution needs to be crowded and ever-expanding curriculum in the education of taken not to wait for women to initiate the conversation about health care professionals, there is an increased trend for nutri- diet or base the advice on assumptions related to women’s tion content to be integrated rather than presented separately socio-economic status as recent research indicated low levels [28]. This integration could be considered as a strength if it of nutrition knowledge and adherence to dietary guidelines is done effectively, as it reflects the complexity of practice, among pregnant women in spite of the majority having high where nutrition is rarely discussed in isolation [28]. How- level of education, motivation, and perceived confidence in ever, interviews with midwifery coordinators identified that adopting a healthy diet [7]. The authors of the study suggested nutrition education integrated across the curricula tended that women’s mistaken beliefs in their ability to eat healthily to be problem-oriented and at times inconsistent and based might prevent them from seeking nutrition information on various assumptions. These assumptions included nursing from health professionals [7]. Midwifery education needs to students’ existing nutrition knowledge, students’ exposure highlight the midwife’s role in public health, especially in the to nutrition while learning about antenatal care, inclusion area of nutrition. This might encourage midwives to become of nutrition in accreditations standards, ease of dietary more proactive and offer the opportunity to every woman to behavioural change, and students’ exposure to nutrition dur- receive appropriate nutrition advice, not just when questions ingclinicalplacement.Thismaybeduetotheabsenceofclear are asked or medical issues are present. national midwifery guidelines on the way nutrition should Most of the nutrition teaching was done by midwives. be included in the curriculum and the absence of specified With the reported inadequacy of nutrition education for competencies on what knowledge and skills the students need midwives, their carriage of the nutrition topics within the to acquire [20]. It is at the discretion of each institution. curricula could be quite variable. Dietitians/other nutrition Generally, nutrition education in health care profession- experts were rarely involved in teaching or reviewing the als’ education has been identified as inadequate [29], even nutrition content as their expertise was not requested or in those professions such as medicine [28, 30], which have considered necessary or could not be guaranteed. Studies received more attention compared to nutrition education in medical education have reported similar findings [35]. within the midwifery discipline. An inability to fit nutrition Even when the expertise of a dietitian was involved and within crowded curricula is one of the main reasons given acknowledged, their knowledge in the area of behaviour for this omission [28]. The failure of professional education change was not fully used. Practical training on how students to equip graduates to face the evolving challenges in the can assess pregnant women’s nutrition requirements and health care system has also been linked to curricula being provide advice to meet these needs was generally lacking. “fragmented, outdated, and static” [31] (p. 1923). Several Dietitians/nutritionists are “university-qualified experts in strategies have been identified which might increase integra- nutrition and dietetics” [36] and their input into the edu- tion of nutrition into health care professionals’ education, cation of other health professionals could be considered including introducing mandatory policies and legislation, highly relevant. Kris-Etherton et al. argued that nutrition adopting new approaches in the education of health care education for health professionals needs to be based on a team professionals (e.g., emphasising a competency-based curricu- approach and that dietitians need to be involved not only in lum and utilising information technology in the teaching the teaching of the content but also in the planning process process), and emphasising a mandatory interprofessional [29]. Including nutrition experts in the review process of team-based education (including defining the specific roles nutrition content might provide some quality oversight and of each discipline in nutrition education) [29]. ensure that the curricula were in line with rapidly occurring 10 Journal of Biomedical Education changes that characterise scientific subjects such as nutrition mapped against the standards [17]. Therefore, nutrition or generally and nutrition in pregnancy specifically. The cost promotion of healthy eating needs to be included in these and limited availability of dietitians/other nutrition experts competency standards. Such standards would make nutrition were indicated as barriers. Strategies to consider would be education consistent across midwifery programmes, so that collaboration with nutrition educators from the same univer- all midwives would have basic knowledge and skills which sities and/or dietitians from community or hospital settings. might translate into the provision of consistent nutrition The development of an online nutrition module by dietitians advice. and other nutrition experts that could be made available Other policies place expectations on midwifery pro- to all Australian midwifery programmes is an alternative grammes to review their inclusion of nutrition within their strategy worth considering. This strategy has been previously curricula. The Standards of Maternity Care of Australia and implemented in the discipline of medicine [35]. New Zealand (revised in 2016) [41] state that information A wide range of nutrition topics was reported to be aboutnutritionanddietshouldbeofferedbyhealthprofes- covered in the surveyed programmes. However, there was sionals to pregnant women at the first contact. Additionally, less focus on topics involving practical or management the recently released clinical antenatal guidelines (models one skills such as “nutrition assessment (e.g., reviewing diet for andtwo)[42,43],whichareintendedforallantenatalcare nutrition requirements of pregnancy)” and “managing weight providers, outline key nutrition related issues in pregnancy, during pregnancy” compared to other topics involving more and the nature of the information that should be provided. theoretical knowledge. These findings are consistent with the results of previous international research [10, 13]. Equipping 4.1. Limitations and Strengths. Limitations of this study midwives with theoretical nutrition knowledge is essential, need to be considered when interpreting the findings. The but so is equipping them with practical or management survey was completed by 23 of 41 coordinators and thus the skills to apply this knowledge, in particular the skills to results do not reflect the nutrition content of all Australian manage weight gain during pregnancy. This is imperative midwifery programmes. However, the results reflect 48% of with the high prevalence of maternal obesity in Australia, accredited programmes in 2012 and are therefore likely to negatively impacting the health of pregnant women and their reflect common practice and professional expectations of babies [33]. Australian midwives have previously cited lack practice. It could be that the study respondents represented of adequate education in the areas of gestational weight gain coordinators with more nutrition-oriented programmes and [11] and maternal obesity and how to manage them [12] as the non-respondents coordinators had even lower coverage of a reason for not giving advice [11]. This is supported by nutrition in their programmes. Another limitation is the self- the findings of our study which indicated that the topic reportingofcurriculumcontent;mostofthecoordinators “managing weight during pregnancy” was covered by a low acknowledged that their estimation of hours allocated to proportion of the surveyed programmes. nutrition was approximate. Identification and quantification The two topics of nutrition during pregnancy which were of nutrition content can be challenging especially when it is least well covered in the programmes were “nutrition during integrated throughout the curriculum. However, estimation pregnancy and different cultural groups” and “nutrition and isacommonmethodofquantifyinghoursallocatedto teenage pregnancy.” These two groups of women are more nutritionintheliterature[13,14].Despiterepeatedinvi- likely to be at risk of suboptimal nutrition status during tations for the interviews, only seven coordinators agreed pregnancy[37,38].Australiaisamulticulturalsocietyandit to participate. The number is small and, therefore, itis wouldbeanticipatedthatmidwivesregularlycareforindivid- unlikely that data saturation was reached. However, par- uals from different cultural and linguistic backgrounds [39]. ticipating coordinators were from both undergraduate and Australian midwives were found to have low to moderate postgraduate programmes (with either integrated content or levels of confidence in advising this group of women about designated nutrition units), providing varied perspectives on diet [9]. Pregnant teenagers are a vulnerable group and have nutrition education within these programmes. A strength high nutrition demands [23]. This group also needs to be of this study is that it is the first to explore the nutrition given specific attention by health professionals, especially as content of midwifery curricula in Australian universities. previous research has indicated that they consider the health The mixed-methods approach is another strength, where professionals as their most trusted source of healthy eating the interviews provided a deeper insight into midwifery information [40]. More coverage of these important topics in coordinators’ perspectives on the nutrition content within midwifery curricula is recommended. their programmes. Contrary to their acknowledging nutrition as important, none of the coordinators interviewed identified lack of clear practical approaches to assess women’s diet or provide 4.2. Future Research. In the future, document analysis could nutrition advice in view of that assessment as barriers. This is be considered by an “authoritative”, independent agency so as in contrast to the ICM [21] core competencies which clearly to maximise access to useful course materials for more accu- articulate that midwives’ competency in the provision of rate evaluation of hours and nutrition content. Prospective nutrition advice to pregnant women needs to be based on studies should explore newly graduated midwives’ nutrition bothknowledgeandskills.TheNationalCompetencyStan- knowledge and their preparation for providing nutrition dards for the Midwife are considered essential in determining advice to pregnant women. Some of the course coordinators what is involved in the midwifery curriculum as it is usually indicated that students would be exposed to more nutrition Journal of Biomedical Education 11 information and practical training in nutrition during clinical References placement. Further research would be required to determine the extent of nutrition education acquired by midwifery [1] P. S. W. Davies, J. Funder, D. J. Palmer, J. Sinn, M. H. Vickers, and C. R. Wall, “Early life nutrition and the opportunity students during clinical placement. The process of midwifery to influence long-term health: an Australasian perspective,” curricula review and how it affects the integration of nutrition JournalofDevelopmentalOriginsofHealthandDisease,vol.7, content into the curricula would be a key area of future no.5,pp.440–448,2016. research. Also needed is examination of effective strategies to [2]E.R.Hillesund,E.Bere,M.Haugen,andN.C.Øverby,“Devel- integrate nutrition education into midwifery programmes. opment of a New Nordic Diet score and its association with gestational weight gain and fetal growth—a study performed in the Norwegian Mother and Child Cohort Study (MoBa),” Public 4.3. Implications for Midwifery Education. The Australian Health Nutrition,vol.17,no.9,pp.1909–1918,2014. clinical antenatal guidelines and the Standards of Maternity [3] E. M. Szwajcer, G. J. Hiddink, L. Maas, M. A. Koelen, and Care of Australia and New Zealand [41, 43] indicate the C. M. J. van Woerkum, “Nutrition-related information-seeking need for minimum requirements of nutrition to be included behaviours of women trying to conceive and pregnant women: in Australian midwifery education and the inclusion of evidence for the life course perspective,” Family Practice,vol.25, nutrition knowledge and skills as core competency areas in supplement 1, pp. i99–i104, 2008. Australian midwifery competency standards. This may be [4] H. E. Porteous, M. A. Palmer, and S. A. Wilkinson, “Informing achieved through consultation and collaboration between maternity service development by surveying new mothers about preferences for nutrition education during their preg- nutrition experts, midwifery educators, and professional nancyinanareaofsocialdisadvantage,”Women and Birth,vol. midwifery bodies such as the ANMAC. Practising midwives 27, no. 3, pp. 196–201, 2014. and pregnant women need to be also included in such con- [5] R. Hughes, J. Maher, E. Baillie, and D. Shelton, “Nutrition and sultations. The findings of this study also have implications physical activity guidance for women in the pre- and post-natal for course coordinators of midwifery programmes in other period: a continuing education needs assessment in primary countries, as similar studies have rarely been undertaken. health care,” Australian Journal of Primary Health,vol.17,no. 2, pp. 135–141, 2011. [6] S. J. de Jersey, J. M. Nicholson, L. K. Callaway, and L. A. 5. Conclusion Daniels, “An observational study of nutrition and physical activity behaviours, knowledge, and advice in pregnancy,” BMC Pregnant women need to receive relevant, timely, and accu- Pregnancy and Childbirth,vol.13,no.1,article115,2013. rate information to prevent excess weight gain and to max- [7] K. Bookari, H. Yeatman, and M. Williamson, “Falling short of imise their nutrition-related health and that of their babies. dietary guidelines—what do Australian pregnant women really Midwiveshaveauniqueroletoplayineducatingpregnant know? A cross sectional study,” Women and Birth,2016. women about their diet and its effects on their health and [8] L. M. Garnweidner, K. Sverre Pettersen, and A. Mosdøl, “Experiences with nutrition-related information during ante- the health of their children. Graduate midwives need to be natal care of pregnant women of different ethnic backgrounds prepared, through their education, to fulfil this role. In order residing in the area of Oslo, Norway,” Midwifery,vol.29,no.12, to meet new clinical antenatal guidelines and standards of pp.E130–E137,2013. maternity care, midwifery education in Australia needs to [9] J.Arrish,H.Yeatman,andM.Williamson,“Australianmidwives reconsider its coverage of nutrition to maximise midwives’ and provision of nutrition education during pregnancy: a ability to provide appropriate nutrition advice to pregnant cross sectional survey of nutrition knowledge, attitudes, and women. confidence,” Women and Birth,vol.29,no.5,pp.455–464,2016. [10] S. Elias and T. Green, “Nutrition knowledge and attitudes of New Zealand registered midwives,” Nutrition and Dietetics,vol. Competing Interests 64, no. 4, pp. 290–294, 2007. [11] J. C. Willcox, K. J. Campbell, P. van der Pligt, E. Hoban, D. The authors declare that there are no competing interests Pidd, and S. Wilkinson, “Excess gestational weight gain: an regarding the publication of this paper. exploration of midwives’ views and practice,” BMC Pregnancy and Childbirth,vol.12,no.1,article102,2012. [12] S. A. Wilkinson and H. Stapleton, “Overweight and obesity Acknowledgments in pregnancy: the evidence—practice gap in staff knowledge, attitudes and practices,” Australian and New Zealand Journal of This research received funding from the Libyan government Obstetrics and Gynaecology,vol.52,no.6,pp.588–592,2012. as part of a doctoral scholarship for (Jamila Arrish). The [13] J. McNeill, J. Doran, F. Lynn, G. Anderson, and F. Alderdice, Libyangovernmenthadnoroleinthestudy.Theauthors “Public health education for midwives and midwifery students: express their appreciation for all midwifery coordinators who a mixed methods study,” BMC Pregnancy and Childbirth,vol.12, no. 1, article 142, 2012. completed the survey and participated in the interviews. The [14] R. Touger-Decker, J. M. Benedict Barracato, and J. O’Sullivan- authors also thank Ms. Cheryl Jecht for her assistance in Maillet, “Nutrition education in health professions programs: transcribing the interviews, Dr. Alexis St. George for her a survey of dental, physician assistant, nurse practitioner, and valuable feedback on the early draft of this paper, and Ms. nurse midwifery programs,” Journal of the American Dietetic Elaine Newby for her assistance in the editing process. Association,vol.101,no.1,pp.63–69,2001. 12 Journal of Biomedical Education

[15] S. Elias and S. Stewart, “Developing nutrition within the [29] P. M. Kris-Etherton, S. R. Akabas, C. W. Bales et al., “The need midwifery curriculum,” British Journal of Midwifery,vol.13,no. to advance nutrition education in the training of health care 7,pp.456–460,2005. professionals and recommended research to evaluate imple- [16] K. M. Kolasa, B. Zinn, and N. Moss, “Nutrition education of mentation and effectiveness,” The American Journal of Clinical nurse-midwives: one example,” Topics in Clinical Nutrition,vol. Nutrition,vol.99,no.5,pp.1153S–1166S,2014. 12,no.3,pp.58–62,1997. [30] K. M. Adams, K. C. Lindell, M. Kohlmeier, and S. H. Zeisel, [17] ANMAC, Midwife Accreditation Standards 2014,Australian “Status of nutrition education in medical schools,” American Nursing and Midwifery Accreditation Council, Canberra, Journal of Clinical Nutrition,vol.83,no.4,pp.941S–944S,2006. Australia, 2014, http://www.anmac.org.au/sites/default/files/ [31] J. Frenk, L. Chen, Z. A. Bhutta et al., “Health professionals for documents/ANMAC Midwife Accreditation Standards 2014 a new century: transforming education to strengthen health .pdf. systems in an interdependent world,” The Lancet,vol.376,no. [18] ANMC, Standards and Criteria for the Accreditation of 9756, pp. 1923–1958, 2010. Nursing and Midwifery Courses Leading to Registration, [32] R. Johanson, M. Newburn, and A. Macfarlane, “Has the med- Enrolment, Endorsement and Authorisation in Australia—With icalisation of childbirth gone too far?” British Medical Journal, Evidence Guide, Australian Nursing and Midwifery Council, vol.324,no.7342,pp.892–895,2002. Canberra, Australia, 2009, http://www.google.com.au/url?sa= [33]H.D.McIntyre,K.S.Gibbons,V.J.Flenady,andL.K.Callaway, t&rct=j&q=&esrc=s&source=web&cd=4&ved=0ahUKEwjU7- “Overweight and obesity in Australian mothers: epidemic or ZSMz57QAhWCkpQKHd7yD7wQFggtMAM&url=http%3A% endemic?” Medical Journal of Australia,vol.196,no.3,pp.184– 2F%2Fwww.ahpra.gov.au%2Fdocuments%2Fdefault.aspx%3 188, 2012. Frecord%3DWD10%252F1905%26dbid%3DAP%26chksum% [34] ACM, Philosophy for Midwifery, Australian College of Mid- 3D%252FJzNzArsTlcD8aivPe3CAA%253D%253D&usg=AFQ- wives, Norwood, Australia, 2004, https://www.midwives.org jCNF90EYWIr2xIk1vc2S2jEKfG 60hA. .au/midwifery-philosophy. [19] ANMC, National Competency Standards for the Midwife, [35] K. M. Adams, M. Kohlmeier, M. Powell, and S. H. Zeisel, “Nutri- Australian Nursing and Midwifery Council, Canberra, tion in medicine: nutrition education for medical students and Australia, 2006, http://www.google.com.au/url?sa=t&rct=j&q= residents,” NutritioninClinicalPractice,vol.25,no.5,pp.471– &esrc=s&source=web&cd=1&sqi=2&ved=0ahUKEwim8P2rz- 480, 2010. p7QAhWBipQKHVsSAEsQFggaMAA&url=http%3A%2F%2F www.nursingmidwiferyboard.gov.au%2Fdocuments%2Fdefault [36] DAA, For Health Professionals, Dietitians Association of Aus- .aspx%3Frecord%3DWD10%252F1350%26dbid%3DAP%26 tralia, Deakin, Australia, 2014, http://daa.asn.au/for-health- chksum%3DYp0233q3xmE5YVjiy%252Fy0mA%253D%253D professionals/. &usg=AFQjCNHHLIQQPyH72UhRL44JG4-PJW0u g&bvm= [37] P. N. Baker, S. J. Wheeler, T. A. Sanders et al., “A prospective bv.138169073,d.dGo. study of micronutrient status in adolescent pregnancy,” The [20]J.Arrish,H.Yeatman,andM.Williamson,“Midwivesand American Journal of Clinical Nutrition,vol.89,no.4,pp.1114– nutrition education during pregnancy: a literature review,” 1124, 2009. Women and Birth,vol.27,no.1,pp.2–8,2014. [38] G. M. A. Higginbottom, H. Vallianatos, J. Forgeron, D. Gibbons, [21] ICM, Essential Competencies for Basic Midwifery Practice,Inter- F. Mamede, and R. Barolia, “Food choices and practices during national Confederation of Midwives, 2010, http://www.inter- pregnancy of immigrant women with high-risk pregnancies in nationalmidwives.org/assets/uploads/documents/CoreDocu- Canada: a pilot study,” BMC Pregnancy and Childbirth,vol.14, ments/ICM%20Essential%20Competencies%20for%20Basic no. 1, article 370, 2014. %20Midwifery%20Practice%202010,%20revised%202013.pdf. [39] M. Williamson and L. Harrison, “Providing culturally appro- [22]J.W.CreswellandV.L.P.Clark,Designing and Conducting priate care: a literature review,” International Journal of Nursing Mixed Methods Research, Sage Publications Inc, Thousand Studies,vol.47,no.6,pp.761–769,2010. Oaks, Calif, USA, 2nd edition, 2011. [40] N. J. Wise and A. A. Arcamone, “Survey of adolescent views of [23] C. S. Williamson, “Nutrition in pregnancy,” Nutrition Bulletin, healthy eating during pregnancy,” MCN: The American Journal vol.31,no.1,pp.28–59,2006. of Maternal/Child Nursing,vol.36,no.6,pp.381–386,2011. [24] S. A. Wilkinson and D. Tolcher, “Nutrition and maternal health: [41] The Royal Australian and New Zealand College of Obstetricians what women want and can we provide it?” Nutrition and and Gynaecologists, Standards of Maternity Care in Australia Dietetics,vol.67,no.1,pp.18–25,2010. and New Zealand, The Royal Australian and New Zealand [25] Better Health Channel, Pregnancy and Diet, State Government College of Obstetricians and Gynaecologists, Victoria, of Victoria Department of Health and Human Services, 2014, Australia, 2014, https://www.ranzcog.edu.au/RANZCOG SITE/ https://www.betterhealth.vic.gov.au/health/healthyliving/preg- media/DOCMAN-ARCHIVE/Standards%20in%20Maternity nancy-and-diet. %20Care%20(C-Obs%2041)%20Review%20March%202016 .pdf. [26] M. A. Neergaard, F. Olesen, R. S. Andersen, and J. Sondergaard, “Qualitative description—the poor cousin of health research?” [42] Australian Health Ministers’ Advisory Council, Clinical Practice BMC Medical Research Methodology,vol.9,no.1,article52,pp. Guidelines: Antenatal Care-Module 1, Australian Government 1–5, 2009. Department of Health and Aging, Canberra, Australia, 2012, http://www.health.gov.au/antenatal. [27] K. M. Adams, M. Kohlmeier, and S. H. Zeisel, “Nutrition education in U.S. medical schools: latest update of a national [43] Australian Health Ministers’ Advisory Council, Clinical Practice survey,” Academic Medicine,vol.85,no.9,pp.1537–1542,2010. Guidelines: Antenatal Care-Module 2, Australian Government Department of Health and Aging, Canberra, Australia, 2014, [28] K. M. Adams, W. S. Butsch, and M. Kohlmeier, “The state http://www.health.gov.au/antenatal. of nutrition education at US medical schools,” Journal of Biomedical Education,vol.2015,ArticleID357627,7pages,2015. Child Development Research

Autism Economics Journal of Nursing Research and Treatment Research International Biomedical Education Research and Practice

Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of Criminology

Journal of Archaeology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Submit your manuscripts at http://www.hindawi.com

International Journal of Education Population Research Research International

Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Depression Research Journal of Journal of Sleep Disorders and Treatment Anthropology Addiction Research and Treatment Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Geography Psychiatry Journal Journal Current Gerontology & Geriatrics Research

Journal of Urban Studies Aging Research Research Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Appendix F: Abstract presented at the 4th Biennial Multidisciplinary Conference – Breathing New Life into Maternity Care (oral presentation)

Nutrition Education during Pregnancy: What Does the Evidence Show?

Arrish J1, Yeatman H1, Williamson M2 1School of Health Sciences, Faculty of Health and Behavioural Sciences, University of Wollongong, New South Wales, Australia 2School of Nursing, Midwifery and Indigenous Health, Faculty of Health and Behavioural Sciences, University of Wollongong, New South Wales, Australia

The recently released National Maternity Services Plan (2011) clearly emphasises the importance of equipping midwives with all the necessary knowledge and skills to provide high quality maternity services and highlights the issue of obesity during pregnancy. Obesity is just one of the nutrition-related issues during pregnancy. How equipped are midwives to provide sound nutrition education to the women in their care? Objective: This review explored the extent to which the role of midwives in nutrition education during pregnancy has been reported in the literature and identified areas requiring further research. Method: A systematic review of the literature accessed the Web of Science, Scoup, ScienceDirect, ProQuest 5000, and PubMed and the bibliographies of relevant articles were examined to identify more appropriate studies. Included were articles published that provided information about the knowledge, education, and attitudes of midwives toward nutrition during pregnancy. Results: The few studies identified were exploratory and descriptive. It was reported that midwives lacked a basic knowledge of nutrition requirements during pregnancy. Inadequate nutrition education provided in both undergraduate and postgraduate midwifery programs was identified as a contributing factor. Conclusion: Improvement in Australian maternity services requires in-depth research on the health education role of and education for midwives.

Conflicts of interest: none declared. Ethical approval: none required. Preferred presentation type (Concurrent Paper Presentation) Presenting author: Jamila Arrish Appendix G: Abstract presented at the 30th Conference of the International Confederation of Midwives (symposium)

Nutrition and pregnancy – key issues for midwives: Good nutrition and appropriate weight gain during pregnancy are known to be associated with a successful pregnancy and the ongoing health of mother and baby1. Rarely is good nutrition a focus of antenatal care and even weight gain expectations have become downplayed through concerns about ‘regulating’ mothers and causing unnecessary concern 2. There is a trend for women to be overweight or obese when they become pregnant, which is associated with an increased incidence of gestational diabetes and other problems 3, and for mothers to have poor knowledge of their nutritional requirements during pregnancy and lactation 4. Studies have shown that pregnant women are most receptive to educational messages about behaviour change5. However, most midwives are not well educated about nutrition for pregnancy or about the most effective strategies to assist pregnant women with their diet and weight 6,7,8. This symposium will present findings from recent research that identifies gaps in pregnancy care and outlines implications for midwifery education and practice. The symposium will profile recent research in nutrition and weight management during pregnancy and identify key strategies for midwives to use in addressing the issue.

The presenters are an international team of midwives and public health professionals from Australia and Denmark who have particular expertise in research focussed on nutrition and weight management in pregnancy: Jamila Arrish, BSc, MPH, MSc (Nutr&Diet), PhD candidate, Public Health, University of Wollongong, Australia. Khlood Bookari, BSc, MSc (Nutr & Diet), PhD candidate, Public Health, University of Wollongong, Australia. Deborah Davis, RM, BN, MNStudies, PhD, Professor of Midwifery, University of Canberra, Australia. Maralyn Foureur, RM, BA, GradDipClinEpidem, PhD, Professor of Midwifery, University of Technology, Australia. Ellen Aagaard Nøhr, RM, MHSc, PhD, Associate Professor, Department of Public Health, Aarhus University, Denmark. Moira Williamson: RN, RM, CertMcN, BN, M HAdmin, GCHEd, PhD, Associate Professor of Midwifery, Central Queensland University, Australia; Honorary Senior Fellow, University of Wollongong, Australia. Heather Yeatman, BSc, DipEd, GDipND, MPH, DPH, Associate Professor Public Health, University of Wollongong, Australia. Symposium Program:

1. Introduction: (5 minutes) Heather Yeatman / Moira Williamson 2. Nutrition during pregnancy – exploring women's knowledge and models of nutrition communication. (15 minutes) This section will present findings from a study investigating women’s knowledge about the recommended safe and healthy eating practices during pregnancy as well as their readiness for dietary change. The study explored pregnant women’s perceptions about the importance of pregnancy-specific nutrition information and their specific needs for information and models of nutrition communication during pregnancy. The presentation will also discuss the barriers and/or factors that may prevent pregnant women from applying their knowledge to daily food practices. Views of health professionals to the study findings, and their approaches to meet the expressed needs of pregnant women will also be presented. Presenter: Khlood Bookari (other authors: Associate Professor Heather Yeatman, Associate Professor Moira Williamson)

3. Guidelines for weight gain: What is the evidence? (15 minutes) This section will focus on the Institute of Medicines (IOM) Guidelines from 2009, which is implemented in antenatal care in many countries all over the world. Data from the Danish National Birth Cohort, which was an important part of the evidence regarding outcomes in the mother and child, will be presented. Challenges facing midwives when trying to facilitate women’s attempts to meet the guidelines will also be discussed.

Presenter: Associate Professor Ellen Aagaard Nøhr

4. Nutrition and pregnancy – what role for the midwife? (15 minutes) This section will present findings from a study that explored the role of Australian midwives in nutrition education during pregnancy and their perceptions of this role. A review of the nutrition content of curricula for midwifery schools around Australia was also undertaken. This presentation will provide the results for the above two studies. Strategies for assisting midwives to integrate nutrition education into their practice will be discussed. Presenter: Jamila Arrish (other authors: Associate Professor Heather Yeatman, Associate Professor Moira Williamson)

5. Weight and pregnancy – encouraging healthy weight gain; reducing the risks of being overweight (15 minutes) This section presents a recent study undertaken in Australia using a model of group antenatal care, with an emphasis on healthy eating and activity in pregnancy, for women who were classified as overweight and obese. Details of the program content and the collaborative, multidisciplinary method of program development and delivery as well as evidence of the acceptability of the program to women and midwives are included in the presentation.

Presenters: Professor Deb Davis and Professor Maralyn Foureur

6. Summary & discussion – key issues for midwives and midwifery practice (20 minutes) Panel discussion References 1. National Health and Medical Research Council. (2013). Australian Dietary Guidelines. Canberra: National Health and Medical Research Council

2. Stotland NE, Gilbert P, Bogetz A, Harper CC, Abrams B, Gerbert B. (2010), Preventing Excessive Weight Gain in Pregnancy: How Do Prenatal Care Providers Approach Counseling?. J Women’s Health, 19 (4):807-814

3. Nohr EA, Vaeth M, Baker JL, Sorensen TI, Olsen J, Rasmussen KM. (2008), Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. Am J Clin Nutr 2008; 87:1750-1759.

4. McLeod ER, Campbell KJ, Hesketh KD. (2011), Nutrition knowledge: A mediator between socioeconomic position and diet quality in Australian first-time mothers, J A D A, 111(5): 696-704

5. Wilkinson SA, Tolcher D. (2010), Nutrition and maternal health: What women want and can we provide it? Nutr & Diet, 67 (1), 18-25

6. Arrish J, Yeatman H, Williamson M. (2013), Midwives and nutrition education during pregnancy: A literature review. Women and Birth, in press http://dx.doi.org/10.1016/j.wombi.2013.02.003

7. Biro MA, Cant R , Hall H, Bailey C , Sinni S , East C. (2013), How effectively do midwives manage the care of obese pregnant women? A cross sectional survey of Australian midwives. Women and Birth; http://dx.doi.org/10.1016/j.wombi.2013.01.006

8. Davis D, Raymond J, Clements V, Adams C, Mollart L, Teate A, Foureur, M. (2012). Addressing obesity in pregnancy: the design and feasibility of an innovative intervention in NSW, Australia. Women and Birth, 25(4),174-80. Appendix H: Abstract presented at the 31st International Confederation of Midwives (poster)

Making a difference through professionalism: the need for evidence-based nutrition in midwifery education

Jamila Arrish1, Heather Yeatman1, Moira Williamson2

1. University of Wollongong, Wollongong, NSW, Australia. 2. Central Queensland University, Noosaville, QLD, Australia

Background • Nutrition during pregnancy is essential for the wellbeing of the mother and the foetus.

• Midwives have a key role in providing nutrition advice to pregnant women but little is known about how nutrition is positioned in midwifery education.

Purpose/Objective • To ascertain how nutrition is included in the curricula of Australian midwifery programmes and who is providing this education. • To ascertain the views of the course coordinators on midwives’ role in nutrition education and the importance of nutrition in midwifery curricula.

Methods • A cross sectional survey was sent to the course coordinators of the 50 accredited Australian midwifery programmes in 2012.

Key findings • Of the course coordinators invited to participate (n = 44), 52.3% (n = 23) were included in the analysis, representing 48% (n = 24) programmes. • Nutrition was included in all programmes but half had only 5 to <10 hours allocated to nutrition within their curricula, with only two programmes having a designated nutrition unit (Figure 1). • A range of nutrition topics were covered. However, topics such as: weight management, nutrition assessment (65.2%, n = 15), nutrition for pregnant teenagers (47.8%, n = 11) and nutrition for different cultural groups (43.5%, n = 10) were covered less frequently compared to other topics (70%-100% of the

1 programmers covered other topics).

• Dietitians were not often involved in teaching nutrition and few programmes (n = 6) involved experts in reviewing their nutrition curricula.

• The majority of the coordinators agreed on the importance of including nutrition education in midwifery curricula and the significant role of midwives in this area.

100% 90% Postgraduate programmes Undergraduate programmes 80% 70% 60% 50% 40% percentage percentage 30% 20% 10% 0% 5 to <10 10 to < 15 15 hours or <5 hours hours hours more Postgraduate programmes 9.1% 22.7% 9.1% 0.0% Undergraduate programmes 4.5% 27.3% 9.1% 18.2%

Figure 1 Hours allocated to general nutrition and/or nutrition during pregnancy in midwifery curricula by programme type

Conclusion • The nutrition content of Australian midwifery curricula needs improvement to maximise midwives’ role in this area.

• Consistent with other areas of evidence- based midwifery practice, minimum requirements for nutrition education should be considered.

• Inclusion of nutrition knowledge and skills as core competency areas in Australian midwifery competency standards is essential as the midwifery curriculum is usually mapped against the standards.

• More focus also is required on the practical skills needed to tackle contemporary issues such as weight management, nutrition

2 assessment, nutrition for vulnerable groups such as teenagers and women from different backgrounds.

• Greater collaboration between nutrition experts and midwifery official bodies may be warranted. Acknowledgments • This research received funding from the Libyan government as part of a doctoral scholarship for (Jamila Arrish). The Libyan government had no role in the study.

• The authors express their appreciation for all midwifery coordinators who completed the survey.

3 Appendix I: The invitation to participate in the midwives’ survey published in the ACM newsletter Appendix J: Media release

11 NOVEMBER 2016

Study identifies key nutrition knowledge gaps in Australian midwives ACADEMICS CALL FOR BETTER TRAINING OF AUSTRALIAN MIDWIVES TO HELP ADDRESS NUTRITION-RELATED ISSUES IN PREGNANCY Midwives need better support to address the high rates of Australian pregnant women whose diets are not consistent with nutrition guidelines, a new study has found. The study, conducted by public health researchers at the University of Wollongong (UOW) and Central Queensland University, was published in the journal of Women and Birth. It found Australian midwives are well placed to promote nutrition in pregnancy but most have a significant knowledge gap and are not confident discussing nutrition with pregnant women. The survey of more than 300 members of the Australian College of Midwives found while the majority (86 per cent) of midwives believed nutrition during pregnancy was important, their nutrition knowledge was poor in several areas. For example, 79 per cent of respondents did not know how much iodine pregnant women needed. Inadequate levels of iodine can lead to abnormal brain development in the unborn baby. In addition, 73 per cent of respondents did not know how much weight a women of normal weight should gain during pregnancy and 73 per cent did not know the Australian guidelines for how many serves of dairy foods pregnant women need to consume. The study also found midwives only had moderate to low confidence in discussing nutrition issues. “This finding is not surprising,” study co-author Professor Heather Yeatman said. “Only half of the midwives reported they received nutrition education during their degree and about the same number (54 per cent) after registration”. Professor Yeatman is Head of the School of Health and Society at UOW and Vice-President (Development) of the Public Health Association of Australia. She said “this significant knowledge gap needs to be addressed urgently for the sake of health of pregnant women”. “Pregnancy is a time when women are keen to eat well. They want to ensure their babies have a healthy start in life. Poor diet during pregnancy can result in babies being underweight (or overweight), brain dysfunction, loss of intelligence or risk of chronic disease later in life,” she said. “Pregnancy is also a time to reinforce healthy eating habits going forward, as women want to regain their pre-pregnancy weight and young children’s eating behaviours sets down eating patterns for life. All health professionals have a role in educating about and reinforcing healthy eating.” Professor Yeatman said more education is needed, both during midwives’ training and post qualification. “The Australian Government has released clinical practice guidelines for all health professionals involved in antenatal care, which reinforce the need for nutrition education. However, these guidelines are quite general. They also are yet to be translated into professional accreditation requirements that direct professional education programs.” Dietician Jamila Arrish, a PhD student at UOW’s School of Health and Society, who led the study, said she also found those who worked in independent midwifery practices were more knowledgeable than those working in public hospitals, with those working in rural hospitals having the least nutrition knowledge.

Issued by India Lloyd, Media and Corporate Communications Coordinator University of Wollongong, NSW 2522 Australia t: +61 2 4221 4841 | m: +61 428 082 977 | [email protected] | media.uow.edu.au | CRICOS Provider No: 00102E Page 1 of 2 “If they are expected to provide nutrition advice as current clinical guidelines recommend, practising midwives will need continuing education and support from the national bodies of the profession and their work places to help fill their knowledge gaps and improve their confidence levels,” Jamila said.

MEDIA RESOURCES

A copy of the paper can be found at: http://www.sciencedirect.com/science/article/pii/S1871519216000391

MEDIA CONTACTS

Jamila Arrish, PhD student in UOW School of Health and Society, on +61 469 904 125 or [email protected] Professor Heather Yeatman, UOW Schoool of Health and Society, on +61 2 4221 3153, +61 409 849 679 or [email protected] India Lloyd, UOW Media and Corporate Communications Coordinator, on +61 428 082 977 or [email protected]

Issued by India Lloyd, Media and Corporate Communications Coordinator University of Wollongong, NSW 2522 Australia t: +61 2 4221 4841 | m: +61 428 082 977 | [email protected] | media.uow.edu.au | CRICOS Provider No: 00102E Page 2 of 2 Appendix K: The invitation email sent to the members of the ACM to participate in the survey

Invitation to participate in a study on the potential role of midwives in providing nutrition education during pregnancy

Jamila Arrish is undertaking this research as part of a PhD degree in Public Health Nutrition at the University of Wollongong under the supervision of A/Prof Heather Yeatman and Dr Moira Williamson.

You are invited to participate in an online survey about your education, practice and experiences in advising pregnant women about what to eat or drink during pregnancy.

Please share your knowledge and experiences. Your participation will be greatly appreciated and may benefit the wider community of midwives. It will help health experts to better focus on your professional educational needs.

The survey will take less than 15 minutes to complete and is available through this link: https://www.surveymonkey.com/s/T9PNK93

If you have any questions, please do not hesitate to contact Jamila Arrish at [email protected] or on 0422 264 309, A/Prof Heather Yeatman at [email protected] or on 02 4221 3153, or Dr Moira Williamson at [email protected] or on 02 4221 3381. Appendix L: The survey instrument of the midwives’ nutrition knowledge, education, attitudes, and confidence in providing nutrition advice during pregnancy. Exploring the role of midwives in providing nutrition education during

PARTICIPATION INFORMATION SHEET

My name is Jamila Arrish and I am undertaking this research as part of a PhD degree in Public Health nutrition at the University of Wollongong. I have a background in public health and nutrition. My supervisors are A/Prof Heather Yeatman and Dr Moira Williamson.

CONTACT DETAILS OF THE RESEARCHERS

Jamila Arrish PhD research student School of Health Sciences, University of Wollongong Tel: 0422264309 [email protected]

A/Prof Heather Yeatman A/ Professor of Public Health School of Health Sciences, University of Wollongong Tel: 02 4221 3153 [email protected]

Dr Moira Williamson Senior Lecturer School of Nursing, Midwifery and Indigenous Health, University of Wollongong Tel: 02 4221 3381 [email protected]

PURPOSE OF THE RESEARCH The purpose of this research is to explore the current level of nutrition knowledge and attitudes of Australian midwives toward nutrition education during pregnancy. Nutrition during pregnancy is important for both the health of the mother and the health of the developing baby. Pregnant women rely on midwives as their trusted source of information and advice. This is based on the women’s perceptions of the midwives’ expertise. However, little is known regarding the current level of knowledge and attitudes of Australian midwives towards the role of nutrition during pregnancy. This research aims to explore this area. It will be useful to better understand midwives’ professional educational needs into the future. The findings might have direct implications for midwifery education throughout Australia. It may help inform the policy and provide recommendations regarding the way in which nutrition should be integrated in midwifery curricula and practise in a manner that can help midwives deliver better nutrition education services to pregnant women in accordance with the women’s expectations of their expertise and professional role. Ultimately, this may have positive effects on the health of future mothers and babies. Therefore, your participation in this research will be highly appreciated.

METHODS AND DEMANDS ON PARTICIPATNTS If you choose to participate in the suggested study, you will be asked to complete an online survey about the role of nutrition during pregnancy, whether you provide nutrition advice to pregnant women, and your practice in this area. The survey will take approximately 15 minutes and is completely confidential and your responses are non­identifiable. The findings of the survey will be reported in a summery article that will be published in the news letter of the Australian College of Midwives where the invitation to participate in the study was originally published. At the end of the survey you will be provided with a brief introduction to a follow up study further exploring your role in providing nutrition education during pregnancy using a semi­structured interview. If you are interested in the follow up study, you will be directed to another internet site where you can securely provide your details (name, email address, age and years of experience) and consent for us to re­contact you about participating in the second study. This information will be recorded on a separate form and is completely confidential. Your personal details will be kept separate from your survey responses and your two responses cannot be linked. Participants for the follow­up study will be selected using purposive sampling based on age and years of experience to ensure a range of perspectives are included in the study. If you have any questions regarding the research and its procedures, please do not hesitate to contact the researchers at any time on the contact details mentioned above.

Page 1 Exploring the role of midwives in providing nutrition education during POSSIBLE RISKS, INCONVENIENCES AND DISCOMFORT: Apart from the approximately 15 minutes of your time taken to complete the survey, we can foresee no risks or inconveniences for you. Your involvement in the study is voluntary and you may withdraw your participation from the study at any time. However, because the online surveys are anonymous, it will not be possible to withdraw your data from the study once it has been submitted. Refusal to participate in the study will not affect your relationship with the University of Wollongong or your place of employment.

BENEFITS OF THE RESEARCH: This research may provide a basis for future studies and contribute to assisting midwives in their nutrition education role during pregnancy. Findings from this study will be presented in the student’s doctoral thesis, at professional conferences and in academic and professional journals. Anonymity is assured; your identity will not be identifiable in any part of the research as the survey will be anonymous. If you agree to be contacted to participate in the follow up study and leave your personal details we assure that these will be maintained confidential as the online survey for collecting personal details will be separate from the first survey and the two cannot be linked.

ETHICS REVIEW AND COMPLAINTS: This study has been reviewed by the Human Research Ethics Committee (Health and Medical) of the University of Wollongong. If you have any concerns or complaints regarding the way this research has been conducted, you can contact the UOW Ethics Office on (02) 42214457 or rso­[email protected].

Thank you for your interest in this study.

By poceeding to the next page and completing the survey, you give us your consent to participate in this research

Part 1: Nutrition education In this section of the survey we are exploring the education experiences of midwives related to nutrition. *1. Did you receive nutrition information or education during your midwifery degree? (Select one answer)

nmlkj Yes

nmlkj No

nmlkj Do not recall

If yes please specify, if possible, the number of lectures/ education sessions, approximate length of time, where they were offered 5

6

*2. Have you received any form of nutrition information or education since your registration as a midwife? (Select one answer)

nmlkj Yes

nmlkj No

nmlkj Do not recall

If yes please specify, if possible, the number of lectures/ education sessions, approximate length of time, where they were offered 5

6

Page 2 Exploring the role of midwives in providing nutrition education during *3. Are your answers to both questions 'No'

nmlkj Yes

nmlkj No

*4. If you received any form of nutrition information or education during your midwifery education or following registration, who provided that education? (You can select more than one answer if relevant).

gfedc Dietitians/ Nutritionists

gfedc Midwives

gfedc Obstetricians or other doctors

gfedc I do not know

Other (please specify) 5

6

Page 3 Exploring the role of midwives in providing nutrition education during *5. Please tick the content relating to nutrition during pregnancy and /or general nutrition that was covered during this education (You can select more than one answer):

gfedc Nutrition during pregnancy, eg the role of folate, iodine or calcium

gfedc The healthy range of weight gain required for pregnant women during different stages of pregnancy

gfedc Nutrition management of gestational diabetes

gfedc Alcohol and pregnancy

gfedc Reviewing diet for nutrition requirements of pregnancy

gfedc Food safety and preparation during pregnancy (e.g listeria)

gfedc Managing weight during pregnancy

gfedc Nutrition for breastfeeding

gfedc Nutrition during pregnancy and different cultural groups

gfedc Nutrition and teenage pregnancy

gfedc Nutrition­related issues such as managing nausea, constipation or heartburn

gfedc General nutrient information, eg the role of nutrients, vitamins and minerals in the body

gfedc General nutrition, eg prevention of chronic illnesses such as cancer or heart disease

gfedc General food safety

Other (please specify) 5

6

Part 2: Attitudes and confidence toward nutrition education during pregnancy In this section of the survey we ask questions about what you believe the midwives role is in relation to providing nutrition information or education during pregnancy. *6. How important do you think nutrition is during pregnancy? (Select one answer) Very important Moderately important Important Slightly important Not important at all nmlkj nmlkj nmlkj nmlkj nmlkj

*7. How would you rate the role that midwives can play in providing nutrition information or education for pregnant women? (Select one answer) A very significant role Moderately significant Significant Slightly significant Not at all significant nmlkj nmlkj nmlkj nmlkj nmlkj

Page 4 Exploring the role of midwives in providing nutrition education during *8. Do you provide any nutrition­ related advice to pregnant women? (Select one answer)

nmlkj Yes

nmlkj No

If yes please specify the nutrition advice you provide 5

6

*9. How confident do you feel in providing general nutrition ­related advice to pregnant women? (Select one answer) Very confident Moderately confident Confident Slightly confident Not at all confident nmlkj nmlkj nmlkj nmlkj nmlkj

*10. How confident do you feel in discussing the following nutrition issues with pregnant women? (Select one answer for each row) Very confident Moderately confident Confident Slightly confident Not confident at all a­ Weight gain and nmlkj nmlkj nmlkj nmlkj nmlkj obesity

b­ Providing advice on nmlkj nmlkj nmlkj nmlkj nmlkj vitamins

c­1 Vegetarian diets (ovo­ nmlkj nmlkj nmlkj nmlkj nmlkj lacto vegetarian­no animal meats)

c­ 2 Vegan diets (no nmlkj nmlkj nmlkj nmlkj nmlkj animal products)

d­ Diabetes nmlkj nmlkj nmlkj nmlkj nmlkj

e­ Diet of people with nmlkj nmlkj nmlkj nmlkj nmlkj previous or complex medical conditions

f­ Diet of people from nmlkj nmlkj nmlkj nmlkj nmlkj ethnic or minority groups

g­ Post natal nutrition nmlkj nmlkj nmlkj nmlkj nmlkj (breastfeeding)

*11. On what occasions do you discuss nutrition issues with pregnant women? (You can select more than one answer)

gfedc At the first antenatal visit

gfedc At every antenatal visit

gfedc Only when the pregnant woman asks questions

gfedc If the pregnant woman has a medical condition requiring nutrition intervention, such as gestational diabetes.

gfedc I only rarely discuss nutrition issues with pregnant women.

Page 5 Exploring the role of midwives in providing nutrition education during *12. What information sources do you use as the basis for this advice? (You can select more than one answer)

gfedc Midwifery education

gfedc Midwifery journals

gfedc General knowledge

gfedc Governmental or official websites.

gfedc Textbooks

gfedc Other health professionals, such as dietitians

gfedc Internet

gfedc Media (e.g. Television, newspaper)

gfedc Magazines.

Other (please specify) 5

6

*13. Do you have a dietitian’s services or support for pregnant women at your service or hospital? (Select one answer)

nmlkj Yes

nmlkj No

*14. If yes do you make referrals to the dietitian? (Select one answer)

nmlkj Yes

nmlkj No

If yes please specify for what conditions..If no please specify why not 5

6

Page 6 Exploring the role of midwives in providing nutrition education during *15. Do you think your practice as a midwife would benefit from you receiving more nutrition information or education? (Select one answer)

nmlkj Yes

nmlkj No

nmlkj I have not thought about it

Please explain your answer 5

6

*16. Do you think that Australian midwives would benefit from guidelines specifically tailored for them to provide nutrition advice to pregnant women? (Select one answer)

nmlkj Yes

nmlkj No

nmlkj I have not thought about it

Please explain your answer 5

6

Part 3: Pregnancy nutrition knowledge In this section we are exploring midwives’ current knowledge of nutrition relating to pregnancy *17. How do the energy requirements for women change on average during pregnancy? (Select one answer)

nmlkj No change in energy requirements

nmlkj Increase by 1400­1900 KJ per day

nmlkj Increase by 2500­3000 KJ per day

nmlkj Increase by 3500­4000 KJ per day

nmlkj I do not know

Page 7 Exploring the role of midwives in providing nutrition education during *18. Is there a difference in the energy requirements for pregnant women during the three trimesters of pregnancy? (Select one answer)

nmlkj Yes

nmlkj No

nmlkj I do not know

*19. What is the range of healthy weight gain during pregnancy for a woman who commenced her pregnancy at normal weight (Select one answer)

nmlkj 9.0 – 12.0 kg

nmlkj 11.5 ­16.0 kg

nmlkj 17.0 ­ 22.5 kg

nmlkj 23.0 ­ 28.5 kg

nmlkj I do not know

*20. The most important vitamin supplement for vegetarian pregnant women is: (Select one answer)

nmlkj Vitamin C

nmlkj Vitamin B12

nmlkj Folic acid

nmlkj I do not know

*21. What foods should be avoided in pregnancy as a risk of listeria? (You can select more than one answer)

gfedc Soft cheeses

gfedc Hard cheeses

gfedc Pre­prepared salads

gfedc Cold meats

gfedc I do not know

*22. When should women take folic acid supplements? (Select one answer)

nmlkj During the first trimester of pregnancy

nmlkj When she first knows that she is pregnant

nmlkj During the whole pregnancy

nmlkj At least one month before pregnancy and during the first 3 months of pregnancy

nmlkj I do not know

Page 8 Exploring the role of midwives in providing nutrition education during *23. The amount of folic acid supplements needed daily during pregnancy is: (Select one answer)

nmlkj 200 micrograms

nmlkj 500 micrograms

nmlkj 400 micrograms

nmlkj I do not know

*24. What is the recommended number of serves of dairy foods required per day to meet pregnant women’s needs for calcium? (Select one answer)

[1 serve = a glass of milk (250mL), a tub of yogurt (200g) or 2 slices of cheese (40g)]:

nmlkj 1 serve

nmlkj 2 serves

nmlkj 3­4 serves

nmlkj I do not know

*25. If a pregnant woman requires more iron in her diet, which of the following foods are a good source of iron? (Select iron rich sources among the following. You can select more than one answer)

gfedc Red meat

gfedc Legumes

gfedc Sea food

gfedc Green leafy vegetables

gfedc I do not know

*26. What are the recommended iodine requirements per day for a pregnant woman? (Select one answer)

nmlkj 220 microgram

nmlkj 300 microgram

nmlkj 500 microgram

nmlkj I do not know

Page 9 Exploring the role of midwives in providing nutrition education during *27. What advice would you provide to a pregnant woman to minimize the effect of nausea and vomiting during pregnancy? (You can select more than one answer)

gfedc Drink plenty of fluids with meals

gfedc Avoid fatty or spicy foods

gfedc Eat large quantities of food at meal times.

gfedc Minimise odours while cooking

gfedc Eat large snacks every few hours

gfedc Have some dry toast or biscuits before getting out of bed in the morning.

gfedc I do not know

*28. What foods can assist with resolving constipation during pregnancy? (You can select more than one answer)

gfedc Fluids

gfedc Dairy foods

gfedc Fruit and vegetables

gfedc Meat

gfedc I do not know

Part 4: Demographic questions This is the last section of the survey and asks some questions about you. *29. Your age

nmlkj 21­30 years

nmlkj 31­40 years

nmlkj 41­50 years

nmlkj Older than 50 years

*30. Are you

nmlkj Female

nmlkj Male

Page 10 Exploring the role of midwives in providing nutrition education during *31. Your education

nmlkj Bachelor degree of Midwifery

nmlkj Hospital based training­Midwifery

nmlkj Initial midwifery post graduate degree

Other qualification, please specify 5

6

*32. Years of experience

nmlkj Less than 2 years

nmlkj 2­5 years

nmlkj 6­10 years

nmlkj More than 10 years

*33. Principle state/territory of work

nmlkj New South Wales (NSW)

nmlkj Queensland (Qld)

nmlkj South Australia (SA)

nmlkj Tasmania (Tas.)

nmlkj Victoria (Vic.)

nmlkj Western Australia (WA)

nmlkj Australian Capital Territory (ACT)

nmlkj Northern Territory (NA)

*34. Principle place of practice

nmlkj Public hospital

nmlkj Private hospital

nmlkj Independent midwifery practice

*35. Level of maternity services

nmlkj Community

nmlkj Rural hospital

nmlkj Reginal hospital

nmlkj Tertiary referral

Page 11 Exploring the role of midwives in providing nutrition education during *36. Area of midwifery practice

gfedc Antenatal care

gfedc Birthing (Labour) suite

gfedc Postnatal

gfedc Rotation through all the above areas

gfedc Group practice (case load or team midwifery)

gfedc Independent midwifery practice

37. Would you like to add any thing else that was not covered in the survey? 5

6

Thank you for your participation in this study

We will be conducting a qualitative study using in­depth interviews to further explore the role of midwives in providing nutrition information during pregnancy. If you would like to be considered to participate in this study, please click the link below which will take you to a separate survey where you can provide your name, age, years of experience as a midwife and email address. We will use the information about your age and years of experience to select our sample for the second study to ensure a range of perspectives are included in the study. Click here

Page 12 Appendix M: The consent to be contacted for the midwives’ interviews and the contact details

The contact details of the second study

*1. Do you consent for us to contact you by email about participating in a follow­up study?

nmlkj Yes

nmlkj No

2. If you answered yes to the previous question, please provide your name and email address below

Name:

Email Address:

*3. Age: are you :

nmlkj Younger than 35 years

nmlkj Older than 35 years

*4. Years of experience as a midwife

Thank you for your interest in this study Please remeber to return to the original survey page and press the button done Thank you

Page 1 Appendix N: Midwives’ interview guide

1. Can you please describe the model of care you follow/practise as a midwife?

2. I would be interested to hear your views of how food selection and nutrition during pregnancy could influence pregnancy outcomes.

3. What are the most important food issues that you usually discuss with pregnant women during their antenatal visits? What are the issues that should be discussed, from your point of view?

4. In what ways do you think your model of care affects the way you provide nutrition advice?

5. Please describe for me the role you think midwives should have in regard to providing food-related or nutrition advice to women during pregnancy?

• What preparation do you think midwives receive to provide such advice? • What are the barriers that midwives encounter in relation to providing such advice? • What guidelines or sources of information are available to midwives relating to providing nutrition information to pregnant women?

6. What might assist midwives to provide better services for pregnant women in regard to food-related or nutrition advice?

7. Would you like to add anything else?

Thank you for your participation. Appendix O: Coordinators’ survey invitation

Invitation to participate in study on midwifery curricula

My name is Jamila Arrish and I am undertaking research as a part of a PhD degree in Public Health nutrition at the University of Wollongong under the supervision of A/Prof Heather Yeatman and Dr Moira Williamson. I have a background in public health and nutrition.

My research aims to document the extent that ‘nutrition during pregnancy’ is taught within midwifery programs across Australia.

I am writing to invite you to participate in this research because you are listed as the co- ordinator of the midwifery program on your university’s website. We invite you to share your knowledge and experiences with us through participating in an electronic survey.

The survey will take approximately 10 minutes to complete and it is available through this link https://www.surveymonkey.com/s.aspx?sm=RrIyXmuIwHOGO4gS49_2fTJA_3d_3d

At a later time we will be contacting coordinators of midwifery programs to invite them to participate in telephone or Skype interviews to further explore opinions and perceptions in this area. Please email your interest in being involved in these interviews via ‘Reply’ to this email and I will send you further information and contact you to organise a suitable time, date and mode (Skype or telephone) to interview you.

Your participation in the survey and the interview will be greatly appreciated and will contribute to midwifery education in Australia. It will assist us to focus on the professional education needs of midwives in regard to their role in advancing better nutrition during the pregnancy period. If you have any further questions do not hesitate to contact: Jamila Arrish [email protected] 0422 264309, A/Prof Heather Yeatman [email protected] 02 42213153 or Dr Moira Williamson [email protected] 02 42213381.

Thank you for your attention. Jamila Arrish: PhD student, University of Wollongong. https:// www.surveymonkey.com/optout.aspx?sm=RrIyXmuIwHOGO4gS49_2fTJA_3d_3d Appendix P: The survey instrument of the nutrition education in midwifery programmes

Exploring the nutrition content of curricula of midwifery programs in

PARTICIPATION INFORMATION SHEET

My name is Jamila Arrish and I am undertaking this research as a part of a PhD degree in Public Health nutrition at the University of Wollongong under the supervision of A/Prof Heather Yeatman and Dr Moira Williamson. I have a background in public health and nutrition.

PURPOSE OF THE RESEARCH The purpose of the research is to explore nutrition content of curricula of midwifery programs in Australia. Nutrition during pregnancy is important for both the health of mother and the health of the developing baby. Midwives have usual contact with expecting mothers and can play a significant role in educating them about healthy eating during pregnancy. However, what is being taught about nutrition during pregnancy in midwifery schools is currently unknown. Therefore, this research aims to explore this area. The research may be useful to better understand midwives’ professional educational needs (in regard to their role in advancing better nutrition during the pregnancy period) into the future. Ultimately, this may have positive effects on the health of future mothers and babies .Your participation in this research will be highly appreciated.

CONTACT DETAILS OF THE INVESTIGATORS Jamila Arrish PhD research student, School of Health Sciences,University of Wollongong Tel: 0422264309 [email protected]

A/Prof Heather Yeatman A/ Professor of Public Health, School of Health Sciences, University of Wollongong Tel: 02 4221 3153 [email protected]

Dr Moira Williamson Senior Lecturer, School of Nursing, Midwifery and Indigenous Health, University of Wollongong Tel: 02 4221 3381 [email protected]

METHODS AND DEMANDS ON PARTICIPATNTS If you choose to be included, you will be asked to complete an online survey about the content of nutrition curricula within your midwifery program. The survey will take approximately up to 10 minutes. If you have any questions regarding the research and its procedures, please do not hesitate to contact the researchers at any time on the contact details mentioned above.

POSSIBLE RISKS, INCONVENIENCES AND DISCOMFORT Apart from the approximate10 minutes of your time taken to complete the survey, we can foresee no risks or inconvenience for you. Your involvement in the study is voluntary and you may withdraw your participation from the study at any time. Information in the survey that could indirectly identify your institution (eg the type/s of midwifery programs that you coordinate at your university) will not be separately reported, to ensure that attribution can not be imputed to individual responses. Refusal to participate in the study will not affect your relationship with the University of Wollongong or your place of employment.

BENEFITS OF THE RESEARCH This research may provide a basis for future studies and contribute to informing the provision of nutrition curricula in midwifery schools in Australia. Findings from this study will be presented in the student’s thesis and at professional conferences and in academic and professional journals. Anonymity is assured; your identity will not be identified in any part of the research as the survey will be anonymous.

ETHICS REVIEW AND COMPLAINTS This study has been reviewed by the Human Research Ethics Committee (Health and Medical) of the University of Wollongong. If you have any concerns or complaints regarding the way this research has been conducted, you can contact the UOW Ethics Office on (02) 42214457 or rso­[email protected]. Thank you for your interest in this study.

By proceeding to the next page and completing the survey, you give us your consent to participate in this study.

Page 1 Exploring the nutrition content of curricula of midwifery programs in

*1. Are you the coordinator of :

nmlkj Bachelor degree of midwifery

nmlkj Postgraduate degree of midwifery

nmlkj Both bachelor and postgraduate degrees of midwifery

Other (please specify) 5

6

*2. Do you think that midwives have a professional role in nutrition education during pregnancy?

nmlkj Yes

nmlkj No

*3. How significant do you think is this role? Very significant Moderately significant Significant Slightly significant Not at all significant nmlkj nmlkj nmlkj nmlkj nmlkj

*4. How important do you think nutrition education during pregnancy is currently as a component of Australian midwives’ curricula? Very important Moderately important Important Slightly important Not important at all nmlkj nmlkj nmlkj nmlkj nmlkj

*5. How important do you think nutrition education during pregnancy is currently for midwives in clinical practice? Very important Moderately important Important Slightly important Not important at all nmlkj nmlkj nmlkj nmlkj nmlkj

*6. Approximately how many hours in total are spent on teaching general nutrition and/or nutrition during pregnancy in your midwifery program/s? 5

6

Page 2 Exploring the nutrition content of curricula of midwifery programs in *7. What are the professional backgrounds of the providers of the nutrition content in your program/s? (You can select more than one answer)

gfedc Dietitians or nutritionists

gfedc Midwives

gfedc Obstetricians or other doctors

Other (please specify) 5

6

*8. Please tick the topics covered in your curricula regarding general nutrition and/or nutrition during pregnancy. (You can select more than one answer)

gfedc Nutrition during pregnancy. eg the role of folate, iodine or calcium

gfedc The healthy range of weight gain required for pregnant women during different stages of pregnancy

gfedc Nutrition management of gestational diabetes

gfedc Nutrition assessment (e.g. reviewing diet for nutrition requirements of pregnancy)

gfedc Food safety and preparation during pregnancy (e.g listeria)

gfedc Managing weight during pregnancy

gfedc Nutrition for breast­feeding

gfedc Nutrition during pregnancy and different cultural groups

gfedc Nutrition and teenage pregnancy

gfedc Nutrition­related issues such as managing nausea and vomiting, constipation or heartburn

gfedc Alcohol and pregnancy

gfedc General nutrient information, eg the role of nutrients, vitamins and minerals in the body

gfedc General nutrition, eg prevention of chronic illnesses such as cancer or heart disease

gfedc General nutrition for special groups (e.g vegetarians, vegans and different cultural groups)

gfedc General food safety

Other (please specify) 5

6

Page 3 Exploring the nutrition content of curricula of midwifery programs in *9. How often is the nutrition curricula at your program/s reviewed or updated?

nmlkj Annually

nmlkj Every 2­3 years

nmlkj Every 5 years / accreditation cycle

Other (please specify) 5

6

*10. Have you sought experts' opinions (internal or external) to review the nutrition components of your curriculum?

nmlkj Yes

nmlkj No

If yes, please specify the experts involved 5

6

Page 4 Appendix Q: Coordinators’ interview guide

1. Can you please outline how food and nutrition issues are presented within the midwifery curriculum at your institution?

a. What importance, if any, is placed on teaching about nutrition during pregnancy compared to other topics in your program?

b. Who is responsible for the nutrition components in your program? Can you please outline any particular qualifications in nutrition held by these academics/ guests?

2. Can you please outline the development and review activities linked with the nutrition curricula within your program?

3. Please outline how nutrition curriculum within your program is informed by particular pedagogical or professional theoretical models.

4. Are there any particular aspects of the curriculum that assists to prepare your graduates to provide evidence-based nutrition information?

a. Any national standards that you follow?

b. Development of nutrition assessment skills?

c. Practical training in nutrition?

5. How well do you think graduate midwives from your program are prepared to provide evidence-based nutrition information for pregnant women?

a. Are there any particular barriers that may impede them in this role? What facilitates their practise in this role?

6. Do you have any other points that you would like to raise?

Thank you for participation in this study. Appendix R: Participation information sheet for the midwives’ interviews

PARTICIPATION INFORMATION SHEET FOR MIDWIVES (interview)

TITLE: Exploring the role of midwives in providing nutrition education during pregnancy- structured interviews.

My name is Jamila Arrish and I am undertaking this research as part of a PhD degree in Public Health at the University of Wollongong under the supervision of A/P Heather Yeatman and Dr Moira Williamson. I have a background in public health and nutrition.

We are contacting you because you provided us your contact details and expressed interest in participating in this study at the end of the “Exploring the role of midwives in providing nutrition education during pregnancy” online survey. If you are still interested in participating in this study after reading the attached participant information sheet, please sign, scan and return the attached consent form by reply email. You are now being sent this information sheet about interviews with midwives that form the second part of this study. If you choose to be included, you will be asked to participate in a semi structured interview about exploring midwives’ perceptions of their role in providing nutrition education during pregnancy.

Purpose of the research:

The purpose of this research is to explore the perceptions of midwives about their role in providing nutrition education during pregnancy and what might help them to fulfil this role. Pregnancy represents a great opportunity to pass positive messages about healthy eating to pregnant women and their families. Midwives have usual contact with expecting mothers. Therefore, their potential role in nutrition education is significant. However, this area of research is underdeveloped. This research aims to identify midwives’ perceptions regarding their role in providing nutrition education to pregnant women and what are the barriers/factors that hinder or facilitate midwives including nutrition education into their professional roles. Achieving these aims will be useful in providing recommendations to direct currently practising midwives in their nutrition education role. This ultimately may have positive effects on the health of future mothers and babies. Therefore, your participation in this research will be highly appreciated.

INVESTIGATORS:

Jamila Arrish A/Prof Heather Yeatman Dr Moira Williamson

PhD research student A/ Professor of Public Health Senior Lecturer School of Health Sciences, School of Health Sciences, the School of Nursing, University of Wollongong University of Wollongong Midwifery and Indigenous Health at the University of Wollongong Tel: 0422264309 Tel: 02 4221 3153 Tel: 02 42 21 3381 [email protected] [email protected] [email protected]

METHODS AND DEMANDS ON PARTICIPATNTS:

If you choose to participate in this study you will be interviewed and asked questions about your role in nutrition education during pregnancy. The interview may take approximately one hour. Following receipt of your signed consent form, the researcher will contact you via email to seek information on available dates and preferred mode for the interview. The researcher will then telephone you to confirm a suitable time and date. The interview will be conducted either via telephone or Skype and recorded via audiotape and then transcribed. A copy of your transcript can be obtained from the researcher.

If you have any questions regarding the research and its procedures, please do not hesitate to contact the researchers at any time on the contact details mentioned above.

POSSIBLE RISKS, INCONVENIENCES AND DISCOMFORT:

Apart from the approximately one hour of your time taken to be interviewed, we can foresee no risks or inconveniences for you. Your involvement in the study is voluntary and you may withdraw your participation from the study at any time and withdraw any data that you may have provided to that point. Refusal to participate in the study will not affect your relationship with the University of Wollongong or your place of employment.

FUNDING AND BENEFITS OF THE RESEARCH:

This research may provide a basis for future studies and contribute to assisting midwives in their nutrition education role during pregnancy. Findings from this study will be presented in the student’s doctoral thesis and at professional conferences and in academic and professional journals. Confidentiality is assured; your identity will not be identifiable in any part of the research as the responses will be coded.

ETHICS REVIEW AND COMPLAINTS:

This study has been reviewed by the Human Research Ethics Committee (Health and Medical) of the University of Wollongong. If you have any concerns or complaints regarding the way this research has been conducted, you can contact the UOW Ethics Office on (02) 42214457 or [email protected].

Thank you for your interest in this study. Appendix S: Consent form for midwives’ interviews

CONSENT FORM

Exploring the role of midwives in providing nutrition education during pregnancy – structured interview Jamila Arrish

I have been given the information sheet explaining the study titled “Exploring the role of midwives in providing nutrition education during pregnancy- structured interviews” and discussed the research project with Jamila Arrish who is conducting this research as part of a PhD degree in Public Health and is supervised by A/P Heather Yeatman and Dr Moira Williamson in the Faculty of Health and Behavioural Sciences at the University of Wollongong.

I have been advised of the potential risks and burdens associated with this research and have had an opportunity to ask Jamila Arrish any questions that I may have about the research and my participation.

I understand that my participation in this research is voluntary, I am free to refuse to participate and I am free to withdraw from the research at any time and withdraw any data that I may have provided to that point. My refusal to participate or withdrawal of consent will not affect my relationship with the University of Wollongong or my place of employment.

If I have any enquiries about the research, I can contact Jamila Arrish at the Faulty of Health and Behavioural Science, School of Health Sciences. (Telephone number: 0422264309; email address: [email protected]); and A/P Heather Yeatman at the Faculty of Health and Behavioural Science, School of Health Sciences. (Telephone number: 0242213153; email address: [email protected]); or Dr Moira Williamson at the School of Nursing, Midwifery and Indigenous Health at the University of Wollongong (tel:0242213381; email: [email protected]), If I have any concerns or complaints regarding the way this research has been conducted, I can contact the UOW Ethics Office on (02) 42214457 or rso- [email protected].

By signing below I am indicating my consent to my participation in a recorded interview with Jamila Arrish about exploring the role of midwives in providing nutrition education during pregnancy. I understand that the data collected from my participation will be used as part of a course of study to obtain PhD degree in Public Health and it might be published as a doctoral thesis or in journals or presented at conferences and I consent for it to be used in that manner.

Signed Date ......

Name (please print)...... Appendix T: Participation information sheet for midwifery coordinators’ interviews

PARTICIPATION INFORMATION SHEET FOR COORDINATORS OF MIDWIFERY PROGRAMS (interview)

TITLE: Exploring the nutrition content of curricula for midwifery programs in Australia

My name is Jamila Arrish and I am undertaking this research as a part of a PhD degree in Public Health nutrition at the University of Wollongong under the supervision of A/Prof Heather Yeatman and Dr Moira Williamson. I have a background in public health and nutrition.

PURPOSE OF THE RESEARCH:

The purpose of the research is to explore how midwifery schools in Australia incorporate nutrition into their programs by exploring opinions and perceptions of the coordinators of midwifery programs about their programs’ nutrition curricula regarding pregnancy. Nutrition during pregnancy is important for both the health of mother and the health of the developing baby. Midwives have usual contact with expecting mothers and can play a significant role in educating them about healthy eating during pregnancy. However, what is being taught about nutrition during pregnancy in midwifery schools is currently unknown. Therefore; this research aims to explore this area. The research may be useful to better understand midwives’ professional educational needs (in regard to their role in advancing better nutrition during the pregnancy period) into the future. Ultimately, this may have positive effects on the health of future mothers and babies. Your participation in this research will be highly appreciated.

INVESTIGATORS:

Jamila Arrish A/Prof Heather Yeatman Dr Moira Williamson

PhD research student A/ Professor of Public Health Senior Lecturer School of Health Sciences, School of Health Sciences, the School of Nursing, University of Wollongong University of Wollongong Midwifery and Indigenous Health at the University of Wollongong Tel: 0422264309 Tel: 02 4221 3153 Tel: 02 42 21 3381 [email protected] [email protected] [email protected]

METHODS AND DEMANDS ON PARTICIPATNTS: If you choose to be included, you will be interviewed and asked questions about the content of nutrition curricula at your midwifery program and your opinions and experiences in this regard. The interview will be conducted via Skype or telephone. It may take approximately up to one hour. The interview will be recorded via audiotape and transcribed. You will receive a copy of the transcript of your interview should you request it. If you have any questions regarding the research and its procedures, please do not hesitate to contact the researchers in any time on the contact details mentioned above.

POSSIBLE RISKS, INCONVENIENCES AND DISCOMFORT:

Apart from the approximate one hour of your time taken to be interviewed, we can foresee no risks or inconvenience for you. Your involvement in the study is voluntary and you may withdraw your participation from the study at any time and withdraw any data that you may have provided to that point. Refusal to participate in the study will not affect your relationship with the University of Wollongong or your place of employment.

FUNDING AND BENEFITS OF THE RESEARCH:

This research may provide a basis for future studies and contribute to informing the provision of nutrition curricula in midwifery programs in Australia. Findings from this study will be presented in the student’s thesis and at professional conferences and in academic and professional journals. Confidentiality is assured; your identity will not be identified in any part of the research as the responses will be coded.

ETHICS REVIEW AND COMPLAINTS:

This study has been reviewed by the Human Research Ethics Committee (Health and Medical) of the University of Wollongong. If you have any concerns or complaints regarding the way this research has been conducted, you can contact the UOW Ethics Office on (02) 42214457 or [email protected].

Thank you for your interest in this study. Appendix U: Consent form for the midwifery coordinators’ interviews

CONSENT FORM

Exploring the nutrition content of curricula of midwifery programs in Australia (interview) Jamila Arrish

I have been given the information sheet explaining the study titled “Exploring the nutrition content of curricula of midwifery programs in Australia” and discussed the research project with Jamila Arrish who is conducting this research as part of a PhD degree in Public Health nutrition supervised by A/P Heather Yeatman and Dr Moira Williamson in the department of Health and Behavioural Sciences at the University of Wollongong.

I have been advised of the potential risks and burdens associated with this research, which includes the participation in a record-taped via telephone or Skype interview with the researcher, and have had an opportunity to ask Jamila Arrish any questions I may have about the research and my participation.

I understand that my participation in this research is voluntary, I am free to refuse to participate and I am free to withdraw from the research at any time. My refusal to participate or withdrawal of consent will not affect my relationship with the University of Wollongong or my place of employment.

If I have any enquiries about the research, I can contact Jamila Arrish at the Faculty of Health and Behavioural Science, School of Health Sciences (telephone number: 0422264309; email address: [email protected]); and A/P Heather Yeatman at the Faculty of Health and Behavioural Science, School of Health Sciences (telephone number: 0242213153; email address: [email protected]); or Dr Moira Williamson at the School of Nursing, Midwifery and Indigenous Health at the University of Wollongong (tel:0242213381; email: [email protected]), If I have any concerns or complaints regarding the way this research has been conducted, I can contact the UOW Ethics Office on (02) 42214457 or rso- [email protected]. .

By signing below I am indicating my consent to

My participation in an audio-recorded interview with Jamila Arrish regarding nutrition content of curricula of midwifery programs in Australia

I understand that the data collected from my participation will be used as part of a course of study to obtain PhD degree in Public Health by the researcher and it might be published as a thesis, in journals or presented at conferences and I consent for it to be used in that manner.

Signed ...... Date………… Name (please print)...... Appendix V: The ethical approval of the midwives’ study followed by its amendments

APPROVAL In reply please quote: HE12/009 Further Enquiries Phone: 4221 3386 DM:SH

5 April 2012 A/Professor Heather Yeatman Jamila Arrish 2/16 College Place Gwynneville NSW 2500

Dear A/Professor Yeatman Thank you for your letter responding to the HREC review letter. I am pleased to advise that the Human Research Ethics application referred to below has been approved. Ethics Number: HE12/009

Project Title: Exploring the role of midwives in nutrition education during pregnancy Name of Researchers: A/Professor Heather Yeatman, Dr Moira Williamson, Mrs Jamila Arrish

Approval Date: 5 April 2012

Expiry Date: 4 April 2013

The University of Wollongong/ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. The HREC has reviewed the research proposal for compliance with the National Statement and approval of this project is conditional upon your continuing compliance with this document. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu. au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. As evidence of continuing compliance, the Human Research Ethics Committee also requires that researchers immediately report: • proposed changes to the protocol including changes to investigators involved • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. Please note that approvals are granted for a twelve month period. Further extension will be considered on receipt of a progress report prior to expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Research Services Office University of Wollongong NSW 2522 Australia Telephone +61 2 4221 3386 Facsimilie +61 2 4221 4338 [email protected] www.uow.edu.au/research Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee

Research Services Office University of Wollongong NSW 2522 Australia Telephone +61 2 4221 3386 Facsimilie +61 2 4221 4338 [email protected] www.uow.edu.au/research AMENDMENT APPROVAL In reply please quote: HE12/009 Further Enquiries Phone: 4221 3386

13 August 2012

A/Professor Heather Yeatman Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear A/Professor Yeatman, I am pleased to advise that the amendments to the following Human Research Ethics application have been approved.

Ethics Number: HE12/009 Project Title: Exploring the role of midwives in nutrition education during pregnancy Researchers: A/Professor Heather Yeatman, Dr Moira Williamson, Mrs Jamila Arrish Amendments: Invitation to participate in online survey Approval Date: 5 April 2012 Expiry Date: 4 April 2013

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/ ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au AMENDMENT APPROVAL In reply please quote: HE12/009 Further Enquiries Phone: 4221 3386

29 October 2012

A/Professor Heather Yeatman Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear A/Professor Yeatman, I am pleased to advise that the amendments to the following Human Research Ethics application have been approved.

Ethics Number: HE12/009 Project Title: Exploring the role of midwives in nutrition education during pregnancy Researchers: A/Professor Heather Yeatman, Dr Moira Williamson, Mrs Jamila Arrish Amendments: Alternate option for participants to return consent form via pre-paid envelope Approval Date: 25 October 2012 Expiry Date: 4 April 2013

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/ ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au AMENDMENT APPROVAL In reply please quote: HE12/009 Further Enquiries Phone: 4221 3386

12 March 2013

A/Professor Heather Yeatman Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear A/Professor Yeatman,

I am pleased to advise that the amendments to the following Human Research Ethics application have been approved.

Ethics Number: HE12/009 Project Title: Exploring the role of midwives in nutrition education during pregnancy Researchers: A/Professor Heather Yeatman, Dr Moira Williamson, Mrs Jamila Arrish Amendments: The use of a transcription professional to assist in transcribing the qualitative data of the research Approval Date: 12 March 2013 Expiry Date: 4 April 2013

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/ ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow. edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Appendix W: The ethical approval of the coordinators’ study followed by its amendments

INITIAL APPLICATION APPROVAL In reply please quote: HE12/038 Further Enquiries Phone: 4221 3386 DM:MOT

2 March 2012

Mrs Jamila Arrish 2/16 College Place Gwynneville NSW 2500

Dear Mrs Arrish, I am pleased to advise that the application below has been approved.

Ethics Number: HE12/038 Project Title: Exploring the nutrition content of curricula of midwifery programs in Australia Researchers: Mrs Jamila Arrish, A/Prof Heather Yeatman, Dr Moira Williamson Approval Date: 1 March 2012 Expiry Date: 28 February 2013

The University of Wollongong/ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. The HREC has reviewed the research proposal for compliance with the National Statement and approval of this project is conditional upon your continuing compliance with this document. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. As evidence of continuing compliance, the Human Research Ethics Committee also requires that researchers immediately report: proposed changes to the protocol including changes to investigators involved serious or unexpected adverse effects on participants unforseen events that might affect continued ethical acceptability of the project.

Research Services Office University of Wollongong NSW 2522 Australia Telephone: +61 2 4221 3386 Facsimile: +61 2 4221 4338 [email protected] www.uow.edu.au/research Please note that approvals are granted for a twelve month period. Further extension will be considered on receipt of a progress report prior to expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Yours sincerely,

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee cc: A/Professor Heather Yeatman, School of Health Sciences, University of Wollongong AMENDMENT APPROVAL In reply please quote: HE12/038 Further Information Phone: 42213386

19 October 2012

Mrs Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear Mrs Arrish,

I am pleased to advise that the amendments dated 17 October 2012 to the following Human Research Ethics application have been approved. Ethics Number: HE12/038 Project Title: Exploring the nutrition content of curricula of midwifery programs in Australia Name of Researchers: Mrs Jamila Arrish, A/Prof Heather Yeatman, Dr Moira Williamson Amendment/s: Sending separate invitation emails to the co-ordinators of the midwifery programs to participate in the interview part of the study. Amendment Approval Date: 18 October 2012 Expiry Date: 28 February 2013

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: serious or unexpected adverse effects on participants unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/Illawarra and Shoalhaven Local Health District Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely,

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee

Cc: A/Professor Heather Yeatman, School of Health Sciences, University of Wollongong AMENDMENT APPROVAL In reply please quote: HE12/038 Further Enquiries Phone: 4221 3386

29 October 2012

Mrs Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear Mrs Arrish, I am pleased to advise that the amendments to the following Human Research Ethics application have been approved.

Ethics Number: HE12/038 Project Title: Exploring the nutrition content of curricula of midwifery programs in Australia Researchers: Mrs Jamila Arrish, A/Prof Heather Yeatman, Dr Moira Williamson Amendments: Alternate option for participants to return consent form via pre-paid envelope Approval Date: 25 October 2012 Expiry Date: 28 February 2013

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/ ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research. A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow.edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee cc: A/Professor Heather Yeatman, School of Health Sciences, University of Wollongong

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au AMENDMENT APPROVAL In reply please quote: HE12/038 Further Enquiries Phone: 4221 3386

12 March 2013

Mrs Jamila Arrish 2/16 College Place GWYNNEVILLE NSW 2500

Dear Mrs Arrish,

I am pleased to advise that the amendments to the following Human Research Ethics application have been approved.

Ethics Number: HE12/038 Project Title: Exploring the nutrition content of curricula of midwifery programs in Australia Researchers: Mrs Jamila Arrish, A/Prof Heather Yeatman, Dr Moira Williamson Amendments: The use of a transcription professional to assist in transcribing the qualitative data of the research Approval Date: 12 March 2013 Expiry Date: 28 February 2014

Please remember that in addition to reporting proposed changes to your research protocol the HREC requires that researchers immediately report: • serious or unexpected adverse effects on participants • unforseen events that might affect continued ethical acceptability of the project. The University of Wollongong/ ISLHD Health and Medical HREC is constituted and functions in accordance with the NHMRC National Statement on Ethical Conduct in Human Research A condition of approval by the HREC is the submission of a progress report annually and a final report on completion of your project. The progress report template is available at http://www.uow. edu.au/research/rso/ethics/UOW009385.html. This report must be completed, signed by the appropriate Head of School and returned to the Research Services Office prior to the expiry date. If you have any queries regarding the HREC review process, please contact the Ethics Unit on phone 4221 3386 or email [email protected].

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au Yours sincerely

Associate Professor Sarah Ferber Chair, UOW & ISLHD Health and Medical Human Research Ethics Committee cc: A/Professor Heather Yeatman, School of Health Sciences, University of Wollongong

Ethics Unit, Research Services Office University of Wollongong NSW 2522 Australia Telephone (02) 4221 3386 Facsimile (02) 4221 4338 Email: [email protected] Web: www.uow.edu.au