‘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.     

Babies born before arrival to hospital and maternity unit closures in Queensland and Australia

BackgroundEvidence suggests the closure of maternity units is associated with an increase in babies born before arrival (BBA).AimTo explore the association between the number of maternity units in Australia and Queensland by birthing numbers, BBA rate and geographic remoteness of the health district where the mother lives.MethodsA retrospective study utilised routinely collected perinatal data (1992–2011). Pearson correlation tested the relationship between BBA rate and number of maternity units. Linear regression examined this association over time.FindingsDuring 1992–2011, the absolute numbers (N = 22,814) of women having a BBA each year in Australia increased by 47% (N = 836–1233); and 206% (n = 140–429) in Queensland. This coincided with a 41% reduction in maternity units in Australia (N = 623–368 = 18 per year) and a 28% reduction in Queensland (n = 129–93). BBA rates increased significantly across Australia, r = 0.837, n = 20 years, p < 0.001 and Queensland, r = 0.917, n = 20 years, p < 0.001 and this was negatively correlated with the number of maternity units in Australia, r = −0.804, n = 19 years, p < 0.001 and Queensland, r = −0.906, n = 19 years, p < 0.001.ConclusionsThe closure of maternity units over a 20-year period across Australia and Queensland is significantly associated with increased BBA rates. The distribution is not limited to rural and remote areas. Given the high risk of adverse maternal and neonatal outcomes associated with BBA, it is time to revisit the closure of units.     

Where do low risk women live relative to maternity services across Victoria? Expanding access to public homebirth models across Victoria

ProblemCurrently <1% of Australian women give birth at home.BackgroundIn Australia there are very few options for women to access public funded homebirth.AimWe aimed to use geo-mapping to identify the number of women eligible for homebirth in Victoria, based on the criteria of uncomplicated pregnancies and residing within 15–25 kms of suitable maternity services, to plan future maternity care options.MethodsRetrospective study of births between 2015 and 2017 in Victoria, Australia. All women who were identified as having a low risk pregnancy at the beginning of pregnancy were included. The number of women within 15 and 25 km of a suitable Victorian public maternity hospital and catchment boundaries around each hospital were determined.FindingsBetween 2015 and 2017, 126,830 low risk women gave birth in Victoria, of whom half live within 25 km of seven Victorian hospitals. Currently, 2% of suitable women who live close to the current public homebirth models accessed them.DiscussionWe present a method to inform the expansion of maternity service options using Victoria as an example. On the basis of the maximum number of low risk women living close by, we have also identified the Victorian maternity services that would be most suitable for creation of public homebirth or low risk continuity of midwifery models.ConclusionThis approach could can be used to plan other maternity care services.     

Women's access needs in maternity care in rural Tasmania,Australia: A mixed methods study

ObjectivesThis study investigates (i) maternity care access issues in rural Tasmania, (ii) rural women's challenges in accessing maternity services and (iii) rural women's access needs in maternity services.MethodsA mixed-method approach using a survey and semi-structured interviews was conducted. The survey explored women's views of rural maternity services from antenatal to postnatal care, while interviews reinforced the survey results and provided insights into the access issues and needs of women in maternity care.FindingsThe survey was completed by n = 210 women, with a response rate of 35%, with n = 22 follow-up interviews being conducted. The survey indicated the majority of rural women believed antenatal education and check-ups and postnatal check-ups should be provided locally. The majority of women surveyed also believed in the importance of having a maternity unit in the local hospital, which was further iterated and clarified within the interviews. Three main themes emerged from the interview data, namely (i) lack of access to maternity services, (ii) difficulties in accessing maternity services, and (iii) rural women's access needs.ConclusionThe study suggested that women's access needs are not fully met in some rural areas of Tasmania. Rural women face many challenges when accessing maternity services, including financial burden and risk of labouring en route. The study supports the claim that the closure of rural maternity units shifts cost and risk from the health care system to rural women and their families.     

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.     

Implementation of an obstetric triage decision aid into a maternity assessment unit and emergency department

BackgroundThe obstetric triage decision aid (OTDA) consists of 10 common pregnancy complaints with key signs and symptoms generating a triage score based on targeted questioning responses. It was developed to provide a standardised approach for obstetric triage conducted by midwives and emergency nurses as neither professional group are expert in the triage of pregnant and postpartum women.AimTo evaluate implementation of the OTDA into an emergency department (ED) and maternity assessment unit (MAU).MethodsThe OTDA was introduced to the ED and MAU of a hospital in Australia. A range of implementation strategies were utilised and assessed by pre and post staff survey, and a three-month post-audit of unscheduled maternity presentations. The primary outcome was adoption rate of the OTDA. Secondary outcomes were staff confidence and waiting times. Analyses were undertaken using SPSS (v24). Paired analysis was conducted on staff surveys.ResultsThere were a total of 2829 unscheduled presentations: ED (n = 708) and MAU (n = 2121), 88.1% were triaged using the OTDA, used more in the MAU than the ED (93.2% vs 72.7%; p < .001). In the MAU, women seen within 15 min of arrival improved significantly from 42.0% to 78.0%. There was improvement in the self-rated confidence (p = .002) and competence (p = .004) by nurses and midwives to conduct obstetric triage.ConclusionThe introduction of the OTDA required different approaches to change practice. There were improvements in staff self-rated confidence and competence, a reduction in clinical risk associated with under-triage in the ED and improved prioritisation of care in the MAU.     

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.     

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.     

Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay

BackgroundLate-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm.ObjectiveThe aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain.MethodsThe intervention was designed to promote parents’ education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n = 212) and an intervention group (n = 161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups.ResultsInfants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p = 0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p = 0.009).ConclusionThe intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.     

Understanding staff views and experiences of a clinical practice change to reduce stillbirth in South Asian women: A cross-sectional survey

BackgroundIn July 2017, Victoria’s largest maternity service implemented a new clinical practice guideline to reduce the rates of term stillbirth in women of South Asian background.AimTo capture the views and experiences of clinical staff following the implementation of the new clinical guideline.MethodsCross sectional survey of clinical staff providing maternity care in August 2018, 12 months post implementation. Staff were asked to provide their agreement with ten statements assessing: perceived need for the guideline, implementation processes, guideline clarity, and clinical application. Open-ended questions provided opportunities to express concerns and offer suggestions for improvement. The frequency of responses to each question were tabulated. Open ended responses were grouped together to identify themes.FindingsA total of 120 staff completed the survey, most (n = 89, 74%) of whom were midwives. Most staff thought the rationale (n = 95, 79%), the criteria for whom they applied (83%, n = 99), and the procedures and instructions within the guideline were clear (74%, n = 89). Staff reported an increase in workload (72%, n = 86) and expressed concerns related to rationale and evaluation of the guidelines, lack of education for both staff and pregnant South Asian women, increased workload and insufficient resources, patient safety and access to care. Challenges relating to shared decision making and communicating with women whose first language is not English were also identified.DiscussionThis study has identified key barriers to and opportunities for improving implementation and highlighted additional challenges relating to new clinical guidelines which focus on culturally and linguistically diverse women.     

The relationship between birthing related factors and maternal breastfeeding confidence in China

ProblemThe relationship between birthing related factors and breastfeeding confidence remain unknown among Chinese mothers.BackgroundBreastfeeding confidence in the early postpartum period is an important predictor of breastfeeding duration. There are many postpartum and socio-demographic factors that have been linked to breastfeeding confidence. However, the relationship between birthing related factors and this confidence remain unknown.AimTo explore the relationship between birthing related factors and breastfeeding confidence among Chinese mothers.MethodsThis is a cross-sectional study of 450 mothers who were recruited after birth and before discharge from hospital. From November 2018 to March 2019, we collected data related to socio-demographics and obstetric characteristics, as well as the Chinese version of Breastfeeding Self-Efficacy Scale and the Chinese version of Labor Agentry Scale. Associations of birthing related factors with breastfeeding self-efficacy were investigated.ResultsThere was a significant correlation between perception of control during labor and breastfeeding confidence. Multiple linear regression showed that higher perception of control in labor scores were significantly associated with higher breastfeeding self-efficacy scores (B = 0.282, P = <0.001), and lower breastfeeding self-efficacy scores were associated with women living in an extended family (B = −12.622, P = <0.001), perceived of insufficient milk supply (B = −5.514, P = 0.038), mild fatigue (B = −8.021, P = 0.03), moderate fatigue (B = −12.955, P = 0.004).ConclusionThere is a significant relationship between perception of control during labor and maternal breastfeeding confidence in the early postpartum period. Strengthening perception of control during labor can improve breastfeeding self-efficacy. Providing professional and emotional support for women during the intrapartum period should be strengthened.     

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.     

Postnatal gestational diabetes mellitus follow-up: Perspectives of Australian hospital clinicians and general practitioners

Problem

The reasons for low postnatal screening rates for women with gestational diabetes mellitus are not well understood. Multiple care providers, settings and changes to diagnostic criteria, may contribute to confusion over postnatal care. Quality of communication between clinicians may be an important influence for the completion of postnatal gestational diabetes mellitus follow-up.

What are the experiences of women with obesity receiving antenatal maternity care? A scoping review of qualitative evidence

ProblemObesity is a major public health problem and is rising in prevalence in child-bearing women. The complications of pregnancy in women with obesity are well documented. Pregnant women with obesity require different maternity care considerations to normal weight women. How women respond to the care of health professionals, determines how likely they will be to engage with it, and thus research into the current care experiences of women with obesity is valuable.ObjectiveThe purpose of this scoping review was to examine the evidence of the antenatal maternity care experiences of women with obesity (BMI ≥ 30 kg/m²).MethodA systematic literature search was conducted for English language publications 2008–2018 using Medline, Scopus, PsycINFO and CINAHL. Following critical appraisal, and a search of the reference lists of primary articles, 17 articles resulted for this review. A thematic synthesis process was used to collate the findings.FindingsFour major themes were identified: 1) inconsistent or absent information regarding weight management, 2) the stigma and stereotyping associated with their obesity, 3) medicalisation and depersonalisation of pregnant women with obesity, and 4) a desire for information and need for change.ConclusionThe findings suggested that based on women’s experiences there is a need for improved education and communication for health care professionals when caring for pregnant women with obesity. Some conflicting information from women in the studies highlight the need for further research in the area, and the implementation of individualised care and continuity of care for pregnant women with obesity.     

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical,reflexive thematic analysis

BackgroundA care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one – warm perineal compresses – has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.QuestionHow does a perineal care bundle impact midwifery practice in Australian maternity hospitals?MethodsPurposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.FindingsWe interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.DiscussionThe bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants’ responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.ConclusionThe introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care.     

Effects of the COVID-19 pandemic on perinatal mental health in Spain: Positive and negative outcomes

BackgroundPrevious studies have shown that perinatal distress has a negative influence on pregnancy outcome and the physiological development of the baby.ObjectiveThe aim of this study was to describe the effects of the COVID-19 pandemic on maternal perinatal mental health in Spain.MethodsSeven hundred and twenty-four women (N = 450 pregnancy, N = 274 postpartum) were recruited online during the pandemic. The Edinburgh Postnatal Depression Scale, the Positive and Negative Affect Schedule, and the Satisfaction With Life Scale were administered. Variables related to sociodemographic information, the COVID-19 pandemic, and perinatal care were also assessed.FindingsThe results showed that 58% of women reported depressive symptoms. Moreover, 51% of women reported anxiety symptoms. On the other hand, a regression analysis for life satisfaction showed that besides the perception about their own health, marital status or being a health practitioner were also significant predictors during pregnancy. However, perception about baby’s health and sleep, perception about their own health, and marital status were significant predictors of life satisfaction during the postpartum stage.DiscussionWomen assessed during the COVID-19 pandemic reported high rates of psychological distress.ConclusionThese results highlight the need of clinical support during this period. Knowing the routes to both distress and well-being may help maternity services to effectively cope with the pandemic.