Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial

Problem and backgroundCaesarean section (CS) rates in Australia and many countries worldwide are high and increasing, with elective repeat caesarean section a significant contributor.AimTo determine whether midwifery continuity of care for women with a previous CS increases the proportion of women who plan to attempt a vaginal birth in their current pregnancy.MethodsA randomised controlled design was undertaken. Women who met the inclusion criteria were randomised to one of two groups; the Community Midwifery Program (CMP) (continuity across the full spectrum — antenatal, intrapartum and postpartum) (n = 110) and the Midwifery Antenatal Care (MAC) Program (antenatal continuity of care) (n = 111) using a remote randomisation service. Analysis was undertaken on an intention to treat basis. The primary outcome measure was the rate of attempted vaginal birth after caesarean section and secondary outcomes included composite measures of maternal and neonatal wellbeing.FindingsThe model of care did not significantly impact planned vaginal birth at 36 weeks (CMP 66.7% vs MAC 57.3%) or success rate (CMP 27.8% vs MAC 32.7%). The rate of maternal and neonatal complications was similar between the groups.ConclusionModel of care did not significantly impact the proportion of women attempting VBAC in this study. The similarity in the number of midwives seen antenatally and during labour and birth suggests that these models of care had more similarities than differences and that the model of continuity could be described as informational continuity. Future research should focus on the impact of relationship based continuity of care.     

Variables related to maternal satisfaction with intrapartum care in Northern Italy

BackgroundThe experience of labour and birth is complex, multidimensional and subjective and has the potential to affect the women and their families physically and emotionally. However, there is a lack of research around maternal satisfaction in Italy.AimTo evaluate mothers’ satisfaction with their childbirth experience in relation to socio-demographic characteristics, obstetric history and intrapartum care variables.MethodsA cross-sectional study involving 277 women who had given birth in a low risk maternity unit in Northern Italy was undertaken. Satisfaction with birth was measured using the Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R). The scale comprises three Sub-Scales: quality of care provided, personal attributes of women and stress experienced during childbirth.FindingsNo socio-demographic variables were related to maternal satisfaction. Multiparous women had a higher satisfaction score (p = 0.020; CI:0.23;2.75). Antenatal class attendance was negatively associated with maternal satisfaction (p = 0.038; CI:−2.58; −0.07). Intrapartum variables that significantly reduced maternal satisfaction were: epidural usage (p = 0.000; CI:−4.66; −2.07), active phase >12 h (p = 0.000; CI:−6.01; −2.63), oxytocin administration (p = 0.000; CI:−5.08; −2.29) and vacuum assisted birth (p = 0.001; CI:−6.50; −1.58). Women with an intact perineum were more likely to be satisfied (p = 0.008; CI:−4.60; −0.69).DiscussionIn accordance with other research, we showed that intrapartum interventions are negatively associated with maternal outcomes and therefore also with maternal satisfaction with birth. The sub-scale that measured Quality of Care provided scored higher than the other two Sub-Scales.ConclusionFurther studies on maternal satisfaction in Italy should be conducted, using the I-BSS-R with the aim to compare outcomes and understand what matters to women during childbirth.     

Women’s reports of satisfaction and respect with continuity of care experiences by students: Findings from a routine,online survey

BackgroundPre-registration midwifery students in Australia undertake a minimum of ten continuity of care experiences with childbearing women. However, women are rarely asked to formally evaluate this care by students.AimTo evaluate data from a routine, web-based survey of women about having a midwifery student provide a continuity of care experience.MethodsAll women (n = 886) recruited by a midwifery student for a continuity of care experience during a 12 month period received an email inviting them to complete an online survey. The survey included personal details, experiences of care, and two scales on Respect and Satisfaction.ResultsA response rate of 57% (n = 501) was achieved. On average students attended six antenatal visits (mean = 5.83) and had six postnatal contacts with women. Most students attended labour and birth (92.6% n = 464). Most women rated overall satisfaction with care by their student as ‘better than they had hoped’. Positive correlations were found between number of antenatal visits and postnatal contact with students on both levels of satisfaction and respect felt by women. Women felt more satisfied when their midwifery student attended labour and birth.ConclusionsThe online survey was feasible and provided valid and reliable feedback from women about their student during a continuity of care experience. Women valued having an ongoing relationship with a student during pregnancy, labour and birth, and postpartum. Pre-registration midwifery education programs should continue to privilege relationship-based care and national standards should support the effective integration of continuity of care experiences.     

Clinical outcomes for women who had continuity of care experiences with midwifery students

BackgroundPre-registration midwifery students in Australia are required to engage in a minimum of ten continuity of care experiences (CoCE). Students recruit and gain consent of each woman to provide CoCE under direct supervision of a registered health professional, usually a midwife. Clinical outcomes for women who had CoCE with a midwifery student placed in a continuity of midwifery care (CMC) or fragmented models are rarely reported.Aims1. analyse clinical outcomes for women experiencing CMC with CoCE by students; 2. analyse clinical outcomes for women in a fragmented care model with CoCE by students; and 3. compare clinical outcomes according to women’s primary model of care.MethodsStudents undertaking a Bachelor of Midwifery program at one Australian university recorded clinical outcomes for women experiencing CoCE during pregnancy [n = 5972] and labour and birth [n = 3933] in an e-portfolio. A retrospective, cohort design compared student recorded maternal data with National Core Maternity Indicators and Queensland Perinatal Data.ResultsMidwifery students providing CoCE reported better or equal clinical outcomes for women compared to population data. Women receiving CoCE had reduced likelihood of tobacco smoking after 20 weeks of pregnancy, episiotomy, and third and fourth degree tears.ConclusionsClinical outcomes for women in fragmented models of care and receiving CoCE by undergraduate, pre-registration midwifery students are equal to or better than State data across 12 variables. CoCE should be offered to all women early in their pregnancy to ensure optimal benefits. Acknowledging midwifery students’ potential to make positive impacts on women’s clinical outcomes may prompt more health services to reconceptualise and foster CoCE.     

Comparing the course of anxiety in women receiving their first or repeated caesarean section: A prospective cohort study

BackgroundAround 30% of births are through caesarean section and repetition rates for receiving a caesarean section are high.AimThe aim of the prospective study was to compare the course of anxiety in women undergoing their first caesarean section and women experiencing a repeated caesarean section.Participants304 women with an indication for an elective caesarean section took part. 155 received their first caesarean section and 149 received a repeated caesarean section.MethodsIn order to measure the course of anxiety on the day of the caesarean section subjective anxiety levels were measured and saliva samples for cortisol determination were taken at admission, during skin closure and two hours after the surgery. Blood pressure and heart rate were documented at skin incision and skin closure.ResultsWomen experiencing their first caesarean section displayed significantly higher anxiety levels compared to women with a repeated caesarean section. Scores of the STAI-State and visual analogue scale for anxiety differed significantly at admission (p = .006 and p < .001) and heart rate and alpha amylase levels were significantly higher at skin closure (p = .027 and p = .029).ConclusionThe results show that previous experience with a caesarean section has a soothing effect. The study aims to sensitize surgeons, anesthetists, nurses and midwives when treating women receiving a caesarean section and encourage them to incorporate soothing interventions, especially for women receiving their first caesarean section to reduce anxiety levels and consequently improve postoperative recovery and patients’ satisfaction.     

Pregnant women voice their concerns and birth expectations during the COVID-19 pandemic in Italy

BackgroundIn March 2020, COVID-19 was declared to be a pandemic. While data suggests that COVID-19 is not associated with significant adverse health outcomes for pregnant women and newborns, the psychological impact on pregnant women is likely to be high.AimThe aim was to explore the psychological impact of the COVID-19 pandemic on Italian pregnant women, especially regarding concerns and birth expectations.MethodsA cross-sectional online survey of pregnant women in Italy was conducted. Responses were analysed for all women and segregated into two groups depending on previous experience of pregnancy loss. Analysis of open text responses examined expectations and concerns before and after the onset of the pandemic.FindingsTwo hundred pregnant women responded to the first wave of the survey. Most (n = 157, 78.5%) had other children and 100 (50.0%) had a previous history of perinatal loss. ‘Joy’ was the most prevalent emotion expressed before COVID-19 (126, 63.0% before vs 34, 17.0% after; p < 0.05); fear was the most prevalent after (15, 7.5% before vs 98, 49.0% after; p < 0.05). Positive constructs were prevalent before COVID-19, while negative ones were dominant after (p < 0.05). Across the country, women were concerned about COVID-19 and a history of psychological disorders was significantly associated with higher concerns (p < 0.05). A previous pregnancy loss did not influence women’s concerns.ConclusionsWomen’s expectations and concerns regarding childbirth changed significantly as a result of the COVID-19 pandemic in Italy. Women with a history of psychological disorders need particular attention as they seem to experience higher levels of concern.     

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care

BackgroundAll competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP).AimTo review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation.MethodsRetrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs.FindingsMCPs (n = 52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n = 23; 44.2%) or vaginal breech birth (n = 7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n = 8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without).ConclusionsMCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.     

Enhanced Antenatal Care: Combining one-to-one and group Antenatal Care models to increase childbirth education and address childbirth fear

BackgroundWe designed and implemented a new model of care, Enhanced Antenatal Care (EAC), which offers a combined approach to midwifery-led care with six one-to-one visits and four group sessions.AimTo assess EAC in terms of women’s satisfaction with care, autonomy in decision-making, and its effectiveness in lowering childbirth fear.MethodsThis was a quasi-experimental controlled trial comparing 32 nulliparous women who received EAC (n = 32) and usual antenatal care (n = 60). We compared women’s satisfaction with care and autonomy in decision-making post-intervention using chi-square test. We administered a Fear of Birth Scale pre- and post-intervention and assessed change in fear of birth in each group using the Cohen’s d for effect size. To isolate the effect of EAC, we then restricted this analysis to women who did not attend classes alongside maternal care (n = 13 in EAC and n = 13 in usual care).FindingsWomen’s satisfaction with care in terms of monitoring their and their baby’s health was similar in both groups. Women receiving EAC were more likely than those in usual care to report having received enough information about the postpartum period (75% vs 30%) and parenting (91% vs 55%). Overall, EAC was more effective than usual care in reducing fear of birth (Cohen’s d = −0.21), especially among women not attending classes alongside antenatal care (Cohen’s d = −0.83).ConclusionThis study is the first to report findings on EAC and suggests that this novel model may be beneficial in terms of providing education and support, as well as lowering childbirth fear.     

Effect of immediate and continuous mother–infant skin-to-skin contact on breastfeeding self-efficacy of primiparous women: A randomised control trial

ObjectiveTo evaluate the effect of mother–infant immediate skin-to-skin contact on primiparous mother's breastfeeding self-efficacy.Study designA randomised control trial.SettingsThe study was conducted in Omolbanin obstetrics hospital (large tertiary hospital), Mashhad, Iran.Participants114 18–35 year-old primiparous, Iranian, healthy and full term mothers who anticipated normal vaginal delivery and intended to breastfeed their babies.InterventionSkin-to-skin contact immediately after birth and then controlling breastfeeding self-efficacy at 28 days postpartum.Main outcome measureMaternal breastfeeding self-efficacy at 28 days postpartum and success in first breastfeeding and mean time of first breastfeeding initiation.ResultsA total of 92 mother–infant dyads (47 dyads in skin-to-skin care skin-to-skin contact group and 45 dyads in routine care group) were monitored and analysed. In skin-to-skin contact group, breastfeeding self-efficacy was 53.42 ± 8.57 SD as compared to 49.85 ± 5.50 SD in routine care group which is significantly higher in skin-to-skin contact group (p = 0.0003).Successful breastfeeding initiation rate was 56.6% in skin-to-skin contact group as compared to 35.6% in routine care group (p = 0.02).Time to initiate first feed was 21.98 ± 9.10 SD min in SSC group vs. 66.55 ± 20.76 min in routine care group (p < 0.001).ConclusionMother–infant immediate skin-to-skin contact is an easy and available method of enhancing maternal breastfeeding self-efficacy. High breastfeeding self-efficacy increases exclusive breastfeeding duration.     

Pregnancy care and birth outcomes for women with moderate to super-extreme obesity

PurposeTo describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity.BackgroundMaternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40.MethodWomen with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women.Results153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1–16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n = 150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n = 74, 48.4%).ConclusionClinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.     

What do midwives fear?

BackgroundThere is evidence that a significant number of women are fearful about birth but less is known about the fears of maternity health providers and how their fear may impact on the women they care for.AimThe aim of this study was to determine the top fears midwives in Australia and New Zealand hold when it comes to caring for childbearing women.MethodFrom 2009 to 2011, 17 workshops were held in Australia and New Zealand supporting over 700 midwives develop skills to keep birth normal. During the workshop midwives were asked to write their top fear on a piece of paper and return it to the presenters. Similar concepts were grouped together to form 8 major categories.FindingsIn total 739 fears were reported and these were death of a baby (n = 177), missing something that causes harm (n = 176), obstetric emergencies (n = 114), maternal death (n = 83), being watched (n = 68), being the cause of a negative birth experience (n = 52), dealing with the unknown (n = 36) and losing passion and confidence around normal birth (n = 32). Student midwives were more concerned about knowing what to do, while homebirth midwives were mostly concerned with being blamed if something went wrong.ConclusionThere was consistency between the 17 groups of midwives regarding top fears held. Supporting midwives with workshops such as dealing with grief and loss and managing fear could help reduce their anxiety. Obstetric emergency skills workshops may help midwives feel more confident, especially those dealing with shoulder dystocia and PPH as they were most commonly recorded.     

Factors associated with a positive childbirth experience in Brazilian women: A cross-sectional study

BackgroundHaving a positive childbirth experience is an increasingly valued outcome. Few studies evaluated the women’s satisfaction with childbirth through face-to-face interviews out of the health service environment. The objective of this study was to identify factors associated with a higher level of satisfaction with the childbirth experience among Brazilian women.MethodsThis cross-sectional study involved 287 women giving birth in two hospitals in southern Brazil. Women who gave birth to healthy newborns at term were randomly selected. Face-to-face interviews were conducted 31–37 days after delivery, at the mothers’ homes, using a structured questionnaire. Satisfaction with the childbirth experience was measured using a Likert-type scale ranging from very satisfied to very dissatisfied. Prevalence ratios (PR) were estimated using Poisson regression with robust variance.ResultsFollowing hierarchical multivariate analysis, the following factors remained associated with a higher level of satisfaction with the childbirth experience: being satisfied with antenatal care (PR = 1.30; 95% confidence interval [95%CI] = 1.06−1.59), understanding the information provided by health professionals during labor and delivery (PR = 1.40; 95%CI = 1.01−1.95), not having reported disrespect and abuse (PR = 1.53; 95%CI = 1.01−2.31), and having had the baby put to the breast within the first hour of life (PR = 1.63; 95%CI = 1.26−2.11). No association was observed with type of delivery or hospital status (public or private).ConclusionsA higher level of satisfaction with the childbirth experience is related to satisfactory antenatal care, a non-abusive, respectful, and informative environment during childbirth, and to the opportunity to breastfeed the baby within the first hour of life. In clinical practice, greater attention to these basic principles of care during pregnancy and delivery could provide more positive experiences during birth.     

Caesarean delivery before 39 weeks associated with selecting an auspicious time for birth in Taiwan

BackgroundCaesarean delivery before 39 weeks of gestation increases the risk of morbidity among infants. Taiwan has one of the highest caesarean rates in the world, but little attention has been paid to this issue. This study aimed to describe the rate of caesarean delivery before 39 weeks gestation among women who did not have labour signs and had a non-emergency caesarean delivery in Taiwan and to examine whether the phenomenon was associated with the Chinese cultural practice of selecting an auspicious time for birth.MethodsWe recruited women at 15–28 weeks of pregnancy at 5 hospitals in northern Taiwan and followed them at 4 or 5 weeks after delivery using structured questionnaires. This analysis included 150 primiparous mothers with a singleton pregnancy who had a non-emergency caesarean delivery without the presence of labour signs.ResultsNinety-three of these women (62.0%) had caesarean deliveries before 39 weeks of gestation. Logistic regression analysis showed that women who had selected an auspicious time for delivery (OR = 2.82, 95% CI: 1.15–6.95) and delivered in medical centres (OR = 5.26, 95% CI: 2.25–12.26) were more likely to deliver before 39 weeks of gestation.ConclusionNon-emergency caesarean delivery before 39 weeks of gestation was common among the study women, and was related to the Chinese cultural practice of selecting an auspicious time for birth. Further studies are needed to examine the risks and benefits associated with timing of caesarean delivery in Taiwan in order to generate a consensus among obstetricians and give pregnant women appropriate information.     

‘I really needed help’: What mothers say about their post-birth care in Queensland,Australia

BackgroundAustralian mothers consistently rate postnatal care as the poorest aspect of their maternity care, and researchers and policymakers have widely acknowledged the need for improvement in how postnatal care is provided.AimTo identify and analyse mothers’ comments about postnatal care in their free text responses to an open ended question in the Having a Baby in Queensland Survey, 2010, and reflect on their implications for midwifery practice and maternity service policies.MethodsThe survey assessed mothers’ experiences of maternity care four months after birth. We analysed free-text data from an open-ended question inviting respondents to write ‘anything else you would like to tell us’. Of the final survey sample (N = 7193), 60% (N = 4310) provided comments, 26% (N = 1100) of which pertained to postnatal care. Analysis included the coding and enumeration of issues to identify the most common problems commented on by mothers. Comments were categorised according to whether they related to in-hospital or post-discharge care, and whether they were reported by women birthing in public or private birthing facilities.ResultsThe analysis revealed important differences in maternal experiences according to birthing sector: mothers birthing in public facilities were more likely to raise concerns about the quality and/or duration of their in-hospital stay than those in private facilities. Conversely, mothers who gave birth in private facilities were more likely to raise concerns about inadequate post-discharge care. Regardless of birthing sector, however, a substantial proportion of all mothers spontaneously raised concerns about their experiences of inadequate and/or inconsistent breastfeeding support.ConclusionWomen who birth in private facilities were more likely to spontaneously report concerns about their level of post-discharge care than women from public facilities in Queensland, and publically provided community based care is not sufficient to meet women's needs. Inadequate or inconsistent professional breastfeeding support remains a major issue for early parenting women regardless of birthing sector.     

Admitting women in active labour: A randomised controlled trial about the effects of protocol use on childbirth method and interventions

AimTo determine the effects of protocol of admitting women in active labour on childbirth method and interventions during labour and childbirth.MethodsThis single-blind randomised clinical trial was conducted in a public hospital in Mazandaran province (Iran) in 2017. Two hundred nulliparous low-risk women were randomly assigned into intervention and control groups. The participant women were admitted in the intervention group using the admission protocol and to the group control by staff midwives and doctors. The admission criteria of the protocol were: the presence of regular, painful contractions, the cervix at least four cm dilated and at least one of the following cues: cervix effaced, and spontaneous rupture of membranes, or “show”. The primary outcome measure was childbirth method. Data were analyzed in SPSS-22 using Mann–Whitney and Chi–square tests. The level of statistical significance was set as p < 0.05.FindingThere were significant differences between the intervention and control groups in the number of caesarian section (CS) (p < 0.001). Two groups had a statistically significant difference in amniotomy (p = 0.003), augmentation by oxytocin (p < 0.001), number of vaginal examinations (p < 0.001) and fundal pressure (p < 0.001).ConclusionsUsing a protocol for admission of low risk nulliparous women in active labour contributed to reduction of the primary caesarean section rate and interventions during childbirth. A risk assessment and using evidence informed guidelines in admission can contribute to reduce unsafe and harmful practices and support normalisation of birth. This is essential for demedicalisation and a useful strategy for reducing primary CS.     

Pain relief for childbirth: The preferences of pregnant women,midwives and obstetricians

ObjectiveTo compare the personal preferences of pregnant women, midwives and obstetricians regarding a range of physical, psychosocial and pharmacological methods of pain relief for childbirth.MethodSelf-completed questionnaires were posted to a consecutive sample of 400 pregnant women booked-in to a large tertiary referral centre for maternity care in South Australia. A similar questionnaire was distributed to a national sample of 500 obstetricians as well as 425 midwives at: (1) the same hospital as the pregnant women, (2) an outer-metropolitan teaching hospital and (3) a district hospital. Eligible response rates were: pregnant women 31% (n = 123), obstetricians 50% (n = 242) and midwives 49% (n = 210).FindingsOverall, midwives had a greater personal preference for most of the physical pain relief methods and obstetricians a greater personal preference for pharmacological methods than the other groups. Pregnant women's preferences were generally located between the two care provider groups, though somewhat closer to the midwives. All groups had the greatest preference for having a support person for labour with more than 90% of all participants wanting such support. The least preferred method for pregnant women was pethidine/morphine (14%).ConclusionThere are differences in the personal preferences of pregnant women, midwives and obstetricians regarding pain relief for childbirth. It is important that the pain relief methods available in maternity care settings reflect the informed preferences of pregnant women.