Nursing Midwifery Commons^™

Co-Design And Feasibility Testing Of A Midwife-Led Birth Debrief: An Implementation Science Project, Kate Buchanan, Phoebe Backhouse, Leanne Graham, Amy O’Meagher, Sara Bayes

Research outputs 2022 to 2026

Background: The period spanning pregnancy, birth and postpartum is characterised by psychosocial as well as physiological changes: many women experience new or worsening mental ill-health during the perinatal period. Midwives play a critical role in supporting and promoting psychosocial health by providing mental health education, counselling and screening. Often this includes a post-birth conversation, guided reflection, or debrief. Information about the effectiveness and experiences of specific and structured midwife-led birth debrief is scant. Aim: Our study aimed to assess the perceived effectiveness, experiences and implementability of a midwife-led birth debriefing intervention in one Australian maternity unit. Methods: A Type II …

Strategies To Improve Outcomes Of Obstetric Emergencies In Sub-Saharan Africa: A Scoping Review, Serah Wachira, Ruth Wagathu, Beth Waweru, Rose Maina, Abednego Ongeso, Constance Sibongile Shumba, Benard Mutwiri, Diana Mbattude, Cliff Aliga, Lucy Kisaka, Peter Gatiti

School of Nursing & Midwifery, East Africa

Background: Obstetric emergencies remain a leading cause of maternal morbidity and mortality in sub-Saharan Africa (SSA) despite increased access to facility-based deliveries and emergency obstetric care. Improving outcomes requires not only life-saving clinical interventions but also effective health system strategies. This review mapped published evidence on strategies used to improve outcomes of obstetric emergencies in SSA.

Objective: This scoping review aimed to identify strategies reported in the literature to improve outcomes of obstetric emergencies in SSA.

Methods: The review was reported in accordance with PRISMA-ScR. A comprehensive electronic search of PubMed, CINAHL, SCOPUS, and CORE identified studies published between January …

Advancing Paternal Perinatal Mental Health: Integrating Qualitative Evidence, Theory, And Measurement Science, Rachael Elizabeth Schmitz

Nursing and Health Sciences

Aim: To advance understanding of paternal perinatal mental health through the integration of qualitative evidence, mid-range theory, and conceptual framework development.

Background: Existing scholarship largely emphasizes prevalence and symptom identification of paternal post partum depression, with limited integration of fathers lived experiences into theory development and assessment frameworks, and mental health nursing practice. Greater integration of qualitative evidence, theory, and measurement science may strengthen the recognition and assessment of paternal distress.

Methods & results: This integrative paper synthesizes findings from a phenomenological study of fathers with postpartum depression, the Reciprocal Adaptation in Postpartum Fathers mid-range nursing theory, and the P- …

Attrition Of The Midwifery Workforce: Understanding Factors Associated With Leaving The Profession, E. Brie Thumm, Amy H. Goh, Elizabeth G. Phillips, Zachary Giano

College of Health Professions Faculty Papers

OBJECTIVE: To understand why advanced practice midwives (certified nurse-midwives and certified midwives) leave the workforce.

STUDY SETTING AND DESIGN: A multi-method, multi-source investigation included secondary analysis of certification data of advanced practice midwives and a cross-sectional online survey with closed- and open-ended items. Advanced practice midwives' active certification data were used to compare self-reported demographic characteristics of advanced practice midwives who reported working in the discipline of midwifery to those who did not (n = 9704). A survey was conducted in 2022 with individuals who allowed their certification to lapse between 2017 and 2021 (n = 303) and individuals who …

Digital Teaching In Midwifery Education Since 2021: A Literature Review Of Trends, Technological Advancements And Challenges, Michelle Gray, Kristina Vogel, Annette Bernloehr, Terri Downer, Melanie Welfare, Nicola H. Bauer

Research outputs 2022 to 2026

Aim: To produce an updated synthesis of digital learning and teaching approaches in midwifery education since 2021. Background: Globally, there is an increasing trend towards using digital technologies in midwifery education with little examination of trends, terminology or impact by midwifery academics. Design: A comprehensive literature review. Methods: Ten databases were searched (2021–March 2025) guided by JBI methodology and PRISMA-ScR reporting, resulting in 36 empirical studies focusing on digital technologies used with midwifery students. The review mapped recent technological developments, associated benefits and emerging challenges. Results: Digital innovations were in 15 countries and ranged from immersive virtual reality, augmented and …

Maternal Prenatal Anxiety And Risk Of Preterm Birth And Low Birthweight: Evidence From A Cumulative Meta-Analysis With Stability Thresholds, Bereket Duko, Desta, Biniyam Sahiledengle, Yohannes Tekalegn Efa, Tenaw Tiruye, Lisa Whitehead, Gavin Pereira, Amanuel Tesfay Gebremedhin

Research outputs 2022 to 2026

Background: We conducted cumulative meta-analyses to quantify the degree to which maternal prenatal anxiety impacts preterm birth (PTB) and low birthweight (LBW), and to identify when findings reached stability, enabling confident recommendations for early interventions. Methods: Following PRISMA guidelines, we systematically searched PubMed/MEDLINE, PsycINFO, Scopus, EMBASE, CINAHL (EBSCO), ProQuest, and the Cochrane Library from database inception to May 7, 2025. The methodological quality of included studies was assessed using the Newcastle–Ottawa Scale. Inverse variance weighted random-effects cumulative meta-analysis was performed to pool adjusted odds ratios (AORs) with sequential inclusion of newly published studies. Stability thresholds were computed to assess sufficiency …

Factors Impacting Western Australian Midwives' Intention To Stay: A Mixed Methods Study, Christine Atkinson, Dianne Bloxsome, Zoe Bradfield, Kate Buchanan, Sarah Dawson, Frances Finch, Sadie Geraghty, Sara Bayes

Research outputs 2022 to 2026

Problem Midwifery workforce sustainability remains a critical concern for maternity services. Existing literature predominantly focuses on burnout and attrition, offering limited insight into what influences midwives’ decisions to remain within specific workplaces. Background Midwives consistently report strong professional commitment alongside growing workforce instability. National data indicate that uncertainty about current roles does not necessarily reflect disengagement from the profession. Understanding workplace-level influences on retention is therefore essential for targeted workforce strategy. Aim To examine how workplace stress and satisfaction with the practice environment are associated with Western Australian midwives’ intention to stay in their current job and in the profession. …

Poor Compliance With Private Nursing And Midwifery Practice Guidelines In Urban Settings In Uganda, Dan Muramuzi, Edson Atwine, Barbara Okiror, Mercy Muwema, Christine Nimwesiga, Laban Muteebwa

School of Nursing & Midwifery, East Africa

Background: Optimal compliance with private practice guidelines is one of the core components of quality improvement in nursing and midwifery professions. Private nursing and midwifery practice guidelines in Uganda were introduced in 2019. However, little has been documented about compliance with these guidelines, despite playing a crucial role in ensuring safe nursing and midwifery practice and maintenance of professional standards.  We assessed the compliance with private nursing and midwifery practice guidelines of Uganda (2019) and explored barriers to optimal compliance with these guidelines in private health facilities licensed by the Uganda Nursing and Midwifery Council (UNMC) in Kampala Metropolitan …

Assessing Impact Of Heat Waves On Pregnancy And Lactation Amidst Climate Change: A Scoping Review., Susan Anyango, Grace Nakate

School of Nursing & Midwifery, East Africa

Background: The escalation of heat waves, attributed to climate change, represents a global public health concern, with pregnant
and lactating women identified as particularly vulnerable due to Physiological and hormonal changes.

Aim: To review the existing research on the effects of heat waves on pregnancy and lactation, identifying potential health risks and outcomes.

Methods: A structured search across PubMed, Scopus, Web of Science, and Google Scholar was conducted using terms related
to heat waves, pregnancy, lactation, and climate change. Inclusion criteria focused on peer-reviewed empirical
studies in English.

Results: Heat waves are linked to increased risks of preterm labor, low …

Descriptive Qualitative Study Of Nursing Students' Perceptions And Behaviors During Student-Led Class Sessions In Uganda, Proscovia Nakaye, Veronica Nakkonde, Mercy Muwema, Grace Nakate

School of Nursing & Midwifery, East Africa

Introduction: Student-led class sessions are a pedagogical approach where students actively engage in the learning process, influencing content, activities, and pace. This method fosters independent learning, communication skills, and teamwork. While some studies have shown the effectiveness of student-led sessions, nursing students often exhibit challenges, such as inattention and negative attitudes, affecting the quality of learning and patient care. Understanding nursing students' perceptions and behaviors in this context is essential for improving nursing education.

Methods: This descriptive qualitative study aimed to explore nursing students' perceptions and behaviors during student-led class sessions at Uganda Christian University. Sixteen direct-entry nursing students …

Prevalence Of Teenage Pregnancy And Associated Factors Among Adolescent Girls In Bobi Subcounty, Northern Uganda., Grace Auma, Margaret Alioru, Geoffrey Kaujju, Grace Nakate

School of Nursing & Midwifery, East Africa

Methodology: A Cross-sectional study design. A survey was conducted among 4893 married girls aged 15-19 years using quantitative methods. Quantitative data was collected through the structured questionnaire, which was administered, data was collected and entered in EPI-INFO 2020 software, and was cleaned and analyzed using STATA version 15.0. Binary logistic regression was done to examine the factors independently associated with teenage pregnancy. A multistage sampling technique was used.

Results: Our study showed that the prevalence of teenage pregnancy in Bobi Sub-County, Omoro District, is high at 27.5%. Significant Factors contributing to the likelihood of teenage pregnancy included those …

Structures And Processes Of Critical Care Nursing Practice: Insights From Four Ugandan Intensive Care Units, Dominic Ogwal Savio, Edrisa Ssemwanga, Winter Patrick, Lameck Ssemogerere, Cliff Aliga

School of Nursing & Midwifery, East Africa

No abstract provided.

The Effect Of Midwife-Led Continuous Labor Support Care On Delivery Mode And Timely Initiation Of Breastfeeding In Primigravida Women In Northwest Ethiopia: A Hybrid Type I Implementation Study, Mengstu Melkamu Asaye, Aragaw, Eden Bishaw Taye, Kihinetu Gelaye Wudineh, Sara Bayes

Research outputs 2022 to 2026

Midwife-led continuous labor and childbirth support reduces the episiotomy rate and increases the rates of vaginal delivery and early initiation of breastfeeding. However, no studies have yet been conducted in Ethiopia. This study aimed to evaluate the effect of midwife-led continuous labor and childbirth support. A quasi-experimental study involving 419 primigravida women compared an intervention given by trained midwives at two hospitals to routine at two others. Data were collected from July to December 2024 through interviews and record reviews. The McNemar test was used to compare changes, with a p-value of less than 0.05. Midwife-led continuous labor support increased …

Global Trends In Bioterrorism And Biosecurity Research Publications (1997–2025): A Scopus Bibliometric Analysis, Festus Mulakoli, Samuel Gesaka, John Mbataru

School of Nursing & Midwifery, East Africa

Introduction: Bioterrorism and biosecurity preparedness are critical pillars of global public health protection and resilience of health systems worldwide. Although this field has grown over the past few decades, there remains limited clarity on how research efforts have evolved and where critical gaps persist, particularly regarding global collaboration and emerging biological threats. To address this, we conducted a bibliometric analysis to map publication trends, influential contributors, and collaboration networks in bioterrorism and biosecurity from 1997 to 2025. This study analyzed global research output, collaboration, and thematic evolution in bioterrorism and biosecurity and identified gaps relevant to preparedness and policy. …

Developing A Pediatric Pain Curriculum For Pediatric Anesthesia Fellows In Sub-Saharan Africa: A Delphi Study, Anisa Bhettay, Rebecca Gray, Romy Parker, Nikki Allorto, Abigail Amponsah, Brian Anderson, Lillian Baranzila, Charles Carapinha, Susan Carolus, O' Brien Kyololo

School of Nursing & Midwifery, East Africa

Background Comprehensive pain management in children requires a specialized skillset, with a limited number of clinicians possessing the level of expertise required to successfully navigate the complexities of holistic care. The emergence of pediatric anesthesia fellowship programs in sub-Saharan Africa presents an opportunity to embed a pediatric pain curriculum for trainees, improving the availability of specialist skill and knowledge in the field. Existing pain curricula fall short in addressing the sociocultural aspects of pediatric pain identified through research as being unique to the African context, and do not include elements of leadership and advocacy training required to navigate the complexities …

Prevalence Of Undiagnosed Dyspepsia, Associated Factors, And Its Relationship With Quality Of Life Among Undergraduate Health Program Students At Makerere University In Uganda, Shamim Nabidda, Christine Atuhurra Kabahinda, David Wagaba, Samuel Okellodepartment Of Clinical Epidemiology And Biostatistics, School Of Medicine, College Of Health Sciences, Makerere University, Kampala, Uganda, Derrick Mugisha, Evan Atwebembeire, Happy Unith, Lule Daniel, Andrew Marvin Kanyike, Ibrahim Edrisa Mutebi, Mark Kaddu Mukasa, Joan N. Kalyango

School of Nursing & Midwifery, East Africa

Introduction:  Dyspepsia affects 6.9% of people globally and significantly impairs quality of life, yet it often remains undiagnosed. Undiagnosed dyspepsia (UD) affects up to one-third of patients and is prevalent among students due to stress, irregular eating, and self-medication. In Uganda, limited access to endoscopy results in many cases being undiagnosed, yet recent data among health program students remains scarce.

Objective:  To determine the prevalence of UD, associated factors, and its relationship with QoL among undergraduate health program students at Makerere University.

Methods:  This was a cross-sectional study involving 378 undergraduate health program students from Makerere University between March and …

Reimagining Peer-Led Support In Doctoral Nursing And Midwifery Education: A Collaborative Autoethnographic Case Study, Gideon U. Johnson, Sachini Thennakoon, Mayumi Kumarage, Emy Toutountzis, Lisa Whitehead

Research outputs 2022 to 2026

Aim: To explore how peer-led initiatives can enhance connection, belonging and sustainability within higher degree by research (HDR) nursing and midwifery programmes. Background: HDR study can be an isolating experience, often characterised by fragmented support and limited opportunities for structured peer learning. While institutions provide formal mechanisms for supervision and progress, less attention has been given to student-led approaches that cultivate inclusive scholarly communities and sustained peer engagement. Design: Collaborative autoethnographic case study. Methods: HDR student representatives and academic staff at Edith Cowan University, Australia (2022–2024), reflected collaboratively on the design, implementation and impact of peer-led initiatives, including monthly hybrid …

Mentorship Practices And Perceptions Of Nursing Faculty At The Aga Khan University In Uganda: A Qualitative Study, Mary Namuguzi, Sarah Nakaziba, Shamim Namukasa, Carolyne Namukwaya, Dinah Kassaman, Arnold Mwanzu, Jackline Estomihi Kiwelu, Duncan Osuka, Nazahed Mkiramweni, Ahmed Sarki

School of Nursing & Midwifery, East Africa

Background Mentorship of new faculty helps to reduce the challenges associated with their new roles, as some lack knowledge of teaching pedagogies. This study assessed the mentorship experiences regarding practices and perceptions of new nursing and midwifery faculty at the Aga Khan University School of Nursing and Midwifery (SONAM) in Uganda.

Methodology This study used a phenomenological design. Data were collected in semistructured interviews with 11 participants, and data saturation was reached. Data were organized with NVivo 12 Pro and analyzed using framework analysis.

Findings The main themes that emerged were mentorship practices, perceptions about mentorship, and proposed mentorship guidelines. …

Intrapartum Experiences Of Gestational Surrogates And Intended Parents In Australia: A Qualitative Study, Jutharat Attawet, Leo Ng, Evie Kendal, Yunjing Qiu, Myles Ojabo, Sarah Jefford, Micah D.J. Peters

Research outputs 2022 to 2026

Background Gestational surrogacy is an increasingly visible, though tightly regulated, pathway to parenthood in Australia, yet intrapartum care remains under-examined. Existing maternity models are grounded in woman-centred care and offer limited guidance for births involving surrogates and intended parents within a triadic care relationship. Objectives To describe the intrapartum experiences of gestational surrogates and intended parents in Australia and to identify care processes that support or hinder respectful, inclusive practice. Methods A descriptive qualitative study was conducted with purposive sampling. Seventeen participants took part between December 2024 and May 2025, comprising nine gestational surrogates and eight intended parents who had …

Intimate Partner Violence Experience, Support Seeking And Coping Strategies Among Pregnant Women In Southwestern Uganda, Eve Katushabe, John Baptist Asiimwe, John Bosco Ndinawe, Editor Abeneitwe, Agnes Katusiime, Gladys Nakidde, Vincent Batwala

School of Nursing & Midwifery, East Africa

Intimate partner violence (IPV) during pregnancy remains a global health challenge. This study aimed to explore pregnant women’s experiences of IPV, support seeking, and coping strategies in Southwestern Uganda. Pregnant women who had experienced IPV during pregnancy were purposively selected and completed in-depth interviews, with data saturation reached after 25 participants. Guided by the feminist theory, data were analyzed deductively and inductively using thematic analysis. Participating pregnant women were exposed to physical violence (e.g., the gravid abdomen being stepped on), psychological violence (e.g., verbal abuse), sexual violence (e.g., being forced into uncomfortable sexual positions), and financial control and manipulation (e.g., …

Caught In The Midwife’S Hands: A Black Feminist Exploration Of Reproductive Health And Justice In Massachusetts, Nina Bakum

Gender, Sexuality, and Intersectionality Studies Honors Papers

No abstract provided.

Midwifery Students' Definitions Of Normal Labor And Birth: A Study From Five Countries, Jalana Lazar, Juliet Wood, Jane Fry, Barbara Baranowska, Urszula Tataj-Puzyna, Debora Dole, Emma Ritchie, Clare Davison, Cindy L. Farley, Felicity Agwu Kalu, Maria Healy, Maria Węgrzynowska

Research outputs 2022 to 2026

Introduction: Internationally, many women and birthing people are receiving maternity care interventions as a routine with no medical indication for their use. This medicalized environment influences midwives' practice and, by extension, midwifery students' clinical learning experiences, gaining knowledge and confidence in facilitating normal labor and birth. To educate midwifery students in the provision of high-quality maternal and newborn care, it is important to explore their understanding of normal labor and birth, as this underpins their philosophy of care and will inform their future practice. Methods: An online survey was developed from a review of current evidence. Following ethical approval, the …

Socioeconomic Influences On Doula Access And Perceived Care Quality Among Black Women Experiencing Severe Maternal Morbidity, Deborah Esene

2026 Spring Honors Capstones Projects

Black women experience disproportionately high rates of maternal morbidity and mortality, making it essential to examine access to and the perceived impact of doula support. This study examines whether socioeconomic status influences access to and the perceived benefits of doula support among Black women who experienced severe maternal morbidity (SMM). Researchers surveyed Black women ages 18-49 who had a live birth within the past two years and experienced SMM. Participants were recruited and completed an online survey in late 2020. Key variables included income, education, doula use, and perceived quality of prenatal, intrapartum, and postpartum care. Among 188 participants, 12.2% …

Quantifying Nurse And Midwife-Led Research Impact: Retrospective Application Of The Framework To Assess The Impact From Translational Health Research (Fait) Model On Two Exemplar Randomised Controlled Trials, Kim Neylon, Rouen, Lisa Whitehead, Greg Sharplin, Kathleen Baird, Marion Eckert

Research outputs 2022 to 2026

Background: Nurse- and midwife-led clinical trials are underrepresented in Australia and New Zealand, despite their potential to improve health outcomes and deliver economic value. Demonstrating the broader impact of such research is essential to inform policy and funding decisions. Aim: To assess the utility of the Framework to Assess the Impact from Translational health research (FAIT) in capturing the translational impact of nurse- and midwife-led randomised controlled trials through retrospective application to two exemplar studies. Methods: FAIT was retrospectively applied to the RSVP (nurse-led) and DAME (midwife-led) trials using three components: Modified Payback, Economic Analysis, and Narrative. Program Logic Models …

Research Publication Performance Of The Australian And New Zealand Nursing And Midwifery Professoriate, Lisa Mckenna, Fiona Bogossian, Simon Cooper, Tracy Levett-Jones, Philippa Seaton

Research outputs 2022 to 2026

Aim: To analyse research publication performance of Australian and New Zealand professors and associate professors of nursing and midwifery, and compare with 2016 data. Methods: A search of university websites was conducted to identify all nursing and midwifery professoriate in Australia and New Zealand. Each individual was then searched in the Scopus database to identify individual total citations, h-index, number of publications, first author Field Weighted Citation Impact (FWCI) and overall FWCI. Comparisons with 2016 data were also undertaken. Results: A total of 304 academics were included, comprising 270 from Australia and 34 from New Zealand, and 169 full professors …

Midwife-Led Birth Debrief: A Concept Analysis, Kate Buchanan, Elliesha O'Reilly, Georgia Wilcox, Sara Bayes, Lauren Kearney, Linda Sweet, Hazel Keedle

Research outputs 2022 to 2026

Background: Psychological birth trauma (PBT) affects approximately 19 % of postnatal women, making its prevention a global priority. Midwives are responsible for providing psychosocial care during the postnatal period to foster the mother-infant relationship, provide education and screening and support positive transitions to parenting. However, the specific attributes of a birth debrief and the role of the midwife in a supporting a woman to review their birth experience is less well documented in regulatory frameworks or scientific literature. This has created significant ambiguity in both clinical practice among health professionals and in research contexts. The lack of a clear understanding …

Nurses’ And Midwives’ Job Satisfaction And Retention During Covid-19: A Scoping Review, Laura Hynes, Sadie Geraghty, Sheena Mcchlery, Aisling Smyth, Reeti Brar, Karen Clark-Burg

Research outputs 2022 to 2026

Background: The COVID-19 pandemic focused attention on the previously well-documented world-wide shortage of nurses and midwives. The pandemic accentuated this crisis, which resulted in nurses and midwives questioning their roles and their careers. The impact of the pandemic on job satisfaction and the intention of nurses and midwives to stay has not been adequately explored. Aim: The aim of this scoping review was to identify and map the literature that describes the intrinsic and extrinsic factors that influenced nurses’ and midwives’ job satisfaction and intent to stay or leave their employment or profession during the COVID-19 pandemic. Method: This scoping …

Delivering Optimal Weight Gain Advice To Pregnant Women By Lead Maternity Carer Midwives In A Real-World Setting To Optimise Health Outcomes (Dot Study): A Case Study Protocol, Kirsten J. Coppell, Nicole Mcgrath, Beverley Lawton, Kendall Stevenson, H. Mel Rackham, Katrina J. Sharples, Trudy Sullivan, Rosemary M. Hall, Helen Paterson

Research outputs 2022 to 2026

Background: Excess gestational weight gain (GWG) occurs in up to 70% of women who birth. Excess GWG increases the risk of adverse outcomes in both mother and baby including gestational diabetes, pre-eclampsia, postpartum weight retention, large for gestational age babies, and adiposity among children. Antenatal lifestyle interventions can limit excess GWG. However, successful translation of interventions into routine antenatal care are seldom, and interventions involving midwives are uncommon. Following a successful feasibility study, the main aims of this study are to determine if the Delivering Optimal weighT gain advice in pregnancy (DOT) intervention is acceptable to midwives, acceptable and accessible …

Women’S Experiences Of Declining Recommended Or Routine Maternity Care: A Systematic Review, Ilyana Mohamed Hussain, Kate Buchanan, Linda Sweet, Sara Bayes

Research outputs 2022 to 2026

Background Women have the right to decline recommended or routine maternity care. While informed choice is increasingly emphasised in maternity care, the experiences of women who decline recommended or routine care remain underexplored. Aims To synthesise evidence on women’s experiences of declining recommended or routine aspects of maternity care. Methods A systematic review was conducted using a structured approach informed by Joanna Briggs Institute (JBI) principles for qualitative synthesis. Eight studies were appraised using the Critical Appraisal Skills Programme (CASP) checklist. Data were analysed through a narrative synthesis process, developing categories and dimensions that were synthesised into overarching themes. Results …

Stakeholders’ Perceptions Of The Roles And Regulations Of Advanced Practice Nursing And Advanced Practice Midwifery, Constance Shumba, Benard Mutwiri, Denis Munene, Rachel Kimani, Beatrice May, Isabel Kambo, Colette Henderson, Irene Mageto, Daniela Lehwaldt, Eunice Ndirangu

School of Nursing & Midwifery, East Africa

Background Advanced practice nursing (APN) and advanced practice midwifery (APM) in Kenya are critical in healthcare system strengthening by expanding access to quality care, particularly in underserved regions. Globally, the International Council of Nurses (ICN) defines APN as a level of nursing practice that requires a minimum of a master’s degree, along with advanced clinical training and competency. Similarly, APM involves midwives with advanced training to provide specialized maternal and neonatal care. In Kenya, the APN and APM concepts were launched in 2020 and are still nascent, and their practice is determined by the context as provided by the country …