Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study

BackgroundIn general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women.AimTo examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth.MethodsA cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital.ResultsEpidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07–2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26–1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation.ConclusionThis study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.     

Regardless of where they give birth,women living in non-metropolitan areas are less likely to have an epidural than their metropolitan counterparts

QuestionCan differences in Australian birth intervention rates be explained by women's residence at the time of childbearing?.MethodsData were collected prospectively via surveys in 1996, 2000, 2003, 2006 and 2009 from women, born between 1973 and 1978, of the Australian Longitudinal Study on Women's Health. Analysis included data from 5886 women who had given birth to their first child between 1994 and 2009. Outcome measures were self-report of birth interventions: pharmacological pain relief (epidural and spinal block analgesia, inhalational analgesia and intramuscular injections), surgical births (an elective or emergency caesarean section) and instrumental births (forceps and ventouse).FindingsPrimiparous women residing in non-metropolitan areas of Australia experienced fewer birth interventions than women residing in metropolitan areas: 43% versus 56% received epidural analgesia; 8% versus 11% had elective caesarean sections; and 16% versus 18% had emergency caesarean sections. Differences in maternal age and private health insurance status at first birth accounted for differences in surgical birth rates but did not fully explain differences in epidural analgesia.ConclusionNon-metropolitan women had fewer birth interventions, particularly epidural analgesia, than metropolitan women. Differences in maternal age and private health insurance do not fully explain the differences in epidural analgesia rates, suggesting care provided to labouring women may differ by area of residence. The difference in epidural analgesia rates may be due to lack of choice in maternity services, however it could also be due to differing expectations leading to differences in birth interventions for primiparous women living in metropolitan and non-metropolitan areas.     

The effect of antenatal screening for depression on neonatal birthweight and gestation

BackgroundAntenatal depression has been associated with poor perinatal outcomes such as preterm birth and low birth weight. Universal screening of perinatal depression has been recommended to improve maternal and pregnancy outcomes.Hypothesis and aimWe hypothesise that screening for antenatal depressive symptoms may reduce the risk of preterm birth and low birth weight. To assess the hypothesis, we explore the association between antenatal depression screening using the Edinburgh Postnatal Depression Scale and neonatal outcomes.MethodsA retrospective analysis of state-wide population-based health administrative data. Inclusion criteria were pregnant women who gave birth to a singleton in Queensland in the second half of 2015 (29,543 women). Logistic regression analyses were run in 27,817 women with information in all variables. Main outcomes were preterm birth (<37 weeks of gestation) and low birth weight (<2500 grs).ResultsWomen who did not complete the screening had increased odds of preterm birth (AOR, 1.56; 95% CI, 1.39–1.74; p < 0.001) and low birth weight (AOR, 1.48; 95% CI, 1.30–1.68; p < 0.001) before and after adjustments for relevant confounders when compared to women who completed the screening. Sensitivity analyses performed in women with spontaneous labour and in women without a diagnosis of depression showed similar results.Conclusion(s)We found an association between screening for depressive symptoms during pregnancy and better neonatal outcomes. However, this result does not necessarily infer causality. Any association may represent a previously unknown benefit to screening, which could support the case for universal antenatal depression screening.     

Using epidemiological and health economic measures to inform maternity staffing decisions: A guide

BackgroundThere is growing concern around unnecessary intervention (particularly caesarean section) at birth in high-income countries. Caseload midwifery care aims to offset this, but is perceived to be costly to health services.AimTo use epidemiological and health economic techniques to estimate health outcomes and cost-savings of different levels of equivalent full time (EFT) midwives working in caseload midwifery care.MethodsTwo simulations were conducted — one assuming 10 EFT midwives working in a caseload model, with 35 women per caseload, and one assuming 50 EFT midwives working in a caseload model, with 45 women per caseload. Both were based on a sample of 5000 women. The main model inputs included rates of health outcomes for women (caesarean section, epidural anaesthesia, and episiotomy) and infants (low birthweight and admissions to special care nursery (SCN) or neonatal intensive care unit (NICU)), and the cost savings associated with health outcome avoidance.FindingsThe first simulation estimated 27 fewer caesarean sections, 12 fewer epidurals, 12 fewer episiotomies, 10 fewer low birthweight births, and 23 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$1,874,715. The second simulation estimated 173 fewer caesarean sections, 76 fewer epidurals, 76 fewer episiotomies, 65 fewer low birthweight births, and 150 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$12,051,741.ConclusionThis study provides local-level decision-makers with a decision-tool to calculate the potentially avoidable health outcomes and cost savings associated with implementing caseload midwifery care in their own service.     

Self reported fear of childbirth and its association with women's birth experience and mode of delivery: A longitudinal population-based study

ObjectiveTo explore fear of childbirth (FOC) during pregnancy and one year after birth and its association to birth experience and mode of delivery.DesignA longitudinal population-based study.PopulationPregnant women who were listed for a routine ultrasound at three hospitals in the middle-north part of Sweden.MethodDifferences between women who reported FOC and who did not were calculated using risk ratios with a 95% confidence interval. In order to explain which factors were most strongly associated to suffer from FOC during pregnancy and one year after childbirth, multivariate logistic regression analyses were used.ResultsFOC during pregnancy in multiparous women was associated with a previous negative birth experience (RR 5.1, CI 2.5–10.4) and a previous emergency caesarean section (RR 2.5, CI 1.2–5.4). Associated factors for FOC one year after childbirth were: a negative birth experience (RR 10.3, CI 5.1–20.7), fear of childbirth during pregnancy (RR 7.1, CI 4.4–11.7), emergency caesarean section (RR 2.4, CI 1.2–4.5) and primiparity (RR 1.9, CI 1.2–3.1).ConclusionFOC was associated with negative birth experiences. Women still perceived the birth experience as negative a year after the event. Women's perception of the overall birth experience as negative seems to be more important for explaining subsequent FOC than mode of delivery. Maternity care should focus on women's experiences of childbirth. Staff at antenatal clinics should ask multiparous women about their previous experience of childbirth. So that FOC is minimized, research on factors that create a positive birth experience for women is required.     

Does antenatal education affect labour and birth? A structured review of the literature

ObjectiveTo undertake a structured review of the literature to determine the effect of antenatal education on labour and birth, particularly normal birth.MethodOvid Medline, CINAHL, Cochrane and Web of Knowledge databases were searched to identify research articles published in English from 2000 to 2012, using specified search terms in a variety of combinations. All articles included in this structured review were assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).FindingsThe labour and birthing effects on women attending antenatal education may include less false labour admissions, more partner involvement, less anxiety but more labour interventions.ConclusionThis literature review has identified that antenatal education may have some positive effects on women's labour and birth including less false labour admissions, less anxiety and more partner involvement. There may also be some negative effects. Several studies found increased labour and birth interventions such as induction of labour and epidural use. There is contradictory evidence on the effect of antenatal education on mode of birth. More research is required to explore the impact of antenatal education on women's birthing outcomes.     

Perinatal factors related to post-traumatic stress disorder symptoms 1–5 years following birth

BackgroundThe relationship between perinatal variables and post-traumatic stress disorder (PTSD) symptoms was studied. However, the role of some variables in PTSD symptoms is unclear.AimDetermine the prevalence of PTSD symptoms after 1 year postpartum and their relationship with perinatal variables.MethodsA cross-sectional study with 1531 puerperal women in Spain. Data were collected on socio-demographic variables, perinatal variables (maternal characteristics, procedures during labour and birth, birth outcomes and time since birth) and the newborn. An online questionnaire was used, which included the Perinatal Post-traumatic Stress Questionnaire (PPQ). Crude and adjusted odds ratios (OR) were calculated using binary logistic regression.Findings7.2% (110) of the women were identified as being at risk for probable PTSD symptoms. Protective factors were having a birth plan respected (aOR 0.44; 95%CI 0.19−0.99), use of epidural analgesia (aOR 0.44; 95%CI 0.24−0.80) and experiencing skin-to-skin contact (aOR 0.33; 95%CI 0.20−0.55). Risk factors were instrumental birth (aOR 3.32; 95%CI1.73−3.39), caesarean section (aOR 4.80; 95%CI 2.51–9.15), receiving fundal pressure (aOR 1.72; 95%CI 1.08–2.74) and suffering a third/fourth degree perineal tear (aOR 2.73; 95%CI 1.27–5.86). The area under the model’s ROC curve was 0.82 (95%CI 0.79−0.83).ConclusionsWomen who experience a normal birth, are psychologically prepared for birth (for example, through use of a birth plan), experience skin-to-skin contact with their newborn, and had a sense of physical control through the use of epidural analgesia, are less likely to experience childbirth as traumatic.     

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.     

Cross-sectional survey of antenatal education attendance among nulliparous pregnant women in Sydney,Australia

BackgroundAntenatal education aims to provide expectant parents with strategies for dealing with pregnancy, childbirth and parenthood and may have the potential to reduce obstetric intervention and fear of childbirth. We aimed to investigate antenatal education attendance, reasons for and barriers to attending, and techniques taught and used to manage labour.MethodsAntenatal and postnatal surveys were conducted among nulliparous women with a singleton pregnancy at two maternity hospitals in Sydney, Australia in 2018. Classes were classified into psychoprophylaxis, birth and parenting, other, or no classes. Reasons for and barriers to attendance, demographic characteristics, and techniques taught and used in labour were compared by class type, using Pearson’s Chi Squared tests of independence.Findings724 women were surveyed antenatally. The main reasons for attending classes were to better manage the birth (86 %), feel more secure in baby care (71 %) and as a parent (60 %); although this differed by class type. Reasons for not attending classes included being too busy (33 %) and cost (27 %). Epidural, breathing techniques, massage and nitrous oxide were the most common techniques taught. Women who attended psychoprophylaxis classes used a wider range of pain relief techniques in labour. Women found antenatal classes useful preparation for birth (94 %) and parenting (74 %). Women surveyed postnatally wanted more information on baby care/sleeping and breastfeeding.ConclusionThe majority of women found antenatal education useful and utilised techniques taught. Education providers should ensure breastfeeding and infant care information is provided, and barriers to attendance such as times and cost should be addressed.     

Perinatal psychosocial assessment of women of refugee background

BackgroundWomen of refugee background may be particularly vulnerable to perinatal mental illness, possibly due to increased exposure to psychosocial stressors associated with their forced migration and post-resettlement adjustment.AimThis study aimed to compare psychosocial risk factors reported by women of refugee background receiving maternity services at a public hospital, to those reported by Australian-born women in the same hospital. It further aimed to examine the referrals offered, and accepted, by the women of refugee background reporting psychosocial risk factors for perinatal mental illness.MethodsA retrospective hospital record review was conducted to compare the antenatal and postnatal psychosocial risk factors of 100 women of refugee background and 100 Australian-born women who gave birth at a public hospital in Victoria between 1 July 2015 and 30 April 2016, and who had completed the Maternity Psychosocial Needs Assessment.FindingsWomen of refugee background were more likely than Australian-born women to report financial concerns and low social support at antenatal assessment, but were less likely to report prior mental health problems than Australian-born women at either assessment point. Both groups reported low rates of family violence compared to published prevalence rates. Of the women of refugee background assessed antenatally, 23% were offered referrals, with 52% take-up. Postnatally, 11.2% were offered referrals, with 93% take-up.Discussion/conclusionThis study showed elevated rates of psychosocial risk factors among women of refugee background, however, possible under-reporting of mental health problems and family violence raises questions regarding how to assess psychosocial risk factors with different cultural groups. Lower antenatal referral take-up suggests barriers to acceptance of referrals may exist during pregnancy.     

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.     

Developing a best practice model of refugee maternity care

BackgroundAbout one third of refugee and humanitarian entrants to Australia are women age 12–44 years. Pregnant women from refugee backgrounds may have been exposed to a range of medical and psychosocial issues that can impact maternal, fetal and neonatal health.Research questionWhat are the key elements that characterise a best practice model of maternity care for women from refugee backgrounds? This paper outlines the findings of a project which aimed at developing such a model at a major maternity hospital in Brisbane, Australia.Participants and methodsThis multifaceted project included a literature review, consultations with key stakeholders, a chart audit of hospital use by African-born women in 2006 that included their obstetric outcomes, a survey of 23 African-born women who gave birth at the hospital in 2007–08, and a survey of 168 hospital staff members.ResultsThe maternity chart audit identified complex medical and social histories among the women, including anaemia, female circumcision, hepatitis B, thrombocytopenia, and barriers to access antenatal care. The rates of caesarean sections and obstetric complications increased over time. Women and hospital staff surveys indicated the need for adequate interpreting services, education programs for women regarding antenatal and postnatal care, and professional development for health care staff to enhance cultural responsiveness.Discussion and conclusionsThe findings point towards the need for a model of refugee maternity care that comprises continuity of carer, quality interpreter services, educational strategies for both women and healthcare professionals, and the provision of psychosocial support to women from refugee backgrounds.     

The perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women: An ethnographic study

BackgroundAcross the globe, many women including economic and humanitarian migrants receive inadequate antenatal care. Understanding the difficulties that migrant women encounter when accessing maternity care, including the approach of health professionals, is necessary because inadequate care is associated with increasing rates of morbidity and mortality. There are very few studies of migrant women’s access to and experience of maternity services when they have migrated from a low- to a middle-income country.AimTo examine the perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women, and to describe women’s experiences of their encounters with health professionals providing maternity care in Ranong Province in southern Thailand.MethodsEthnography informed the study design. Individual interviews were conducted with 13 healthcare professionals and 10 Burmese women before and after birth. Observations of interactions (130 h) between health care providers and Burmese women were also conducted. Data were analysed using thematic analysis.FindingsThe healthcare professionals’ practices differed between the antenatal clinics and the postnatal ward. Numerous barriers to accessing culturally appropriate antenatal care were evident. In contrast, the care provided in the postnatal ward was woman and family centered and culturally sensitive. One overarching theme, “The system is in control’ was identified, and comprised three sub-themes (1) ‘Being processed’ (2) ‘Insensitivity to cultural practices’ and, (3) ‘The space to care’.Discussion and conclusionsThe health system and healthcare professionals controlled the way antenatal care was provided to Burmese migrant women. This bureaucratic and culturally insensitive approach to antenatal care impacted on some women’s decision to engage in antenatal care. Conversely, the more positive examples of woman-centered care evident after birth in the postnatal ward, can inform service delivery.     

The nutrition-related information seeking behaviours and attitudes of pregnant women with a high BMI: A qualitative study

BackgroundThe prevalence of high body mass index is increasing amongst women of child bearing age. High maternal body mass index has ramifications for both mother and baby including increased health risks from gestational diabetes mellitus, caesarean section and stillbirth. Despite the increasing prevalence of high maternal body mass index little is known of the experiences of these women regarding nutrition information access and use during the antenatal period.MethodsA qualitative study using individual interviews was undertaken at a tertiary hospital in south-eastern Australia. Twenty-Eight women with a body mass index ≥30 kg/m² participated. Interviews were audio recorded, transcribed, cross-checked for consistency and entered into a word processing document for further scrutiny. Data was analysed using interpretative phenomenological analysis (IPA). In any phenomenological study the researcher’s objective is to elicit the participant’s views on their lived experiences.FindingsThree major themes emerged: (1) Nutrition-related information attainment; (2) Nutrition-related information management; (3) Nutrition-related information needs and wants.ConclusionThe findings from this study may assist the future development and dissemination of nutrition-related information for pregnant women with a high body mass index. Women want more individualised support regarding nutritional requirements during pregnancy.     

Midwives’ provision of health promotion in antenatal care: A qualitative explorative study

ProblemStudies indicate that health promotion in antenatal care can be improved. Moreover, a schism seems to exist between health promotion and prevention in antenatal care.BackgroundAntenatal care to support and improve maternal health is a core midwifery activity in which prevention as well as HP and woman-centeredness are important.AimTo explore how Danish midwives experienced antenatal care and practiced health promotion.MethodsMidwives undertaking antenatal care were interviewed individually (n = 8) and two focus groups (n = 10) were created. Thematic analysis was performed inductively, and the theoretical models from Piper’s health promotion practice Framework for midwives were used to analyse the midwives’ health promotion approach.FindingsTwo major themes were highlighted. Theme 1: ‘The antenatal care context for health promotion’ described factors contributing to quality in health promotion in antenatal care, such as communication and building relationships with the pregnant women. Theme 2: ‘The health promotion approach in antenatal care’ described both midwife-focused and woman-focused approaches to pregnant women’s health. Barriers to high-quality antenatal care and a holistic health promotion approach were identified, such as shared-care issues, documentation demands and lack of time.DiscussionThe midwives’ experiences were discussed in the context of a health promotion approach. Why midwives practice using a midwife-centred approach has many explanations, but midwives need to learn and help each other understand how they can practice woman-focused care while simultaneously providing prophylactic, evidence-based care.ConclusionMidwives mainly had a midwife-focused approach. To further promote women’s health, midwives need to focus on a woman-focused approach.     

Breaking through the silence in antenatal care: Fetal movement and stillbirth education

BackgroundFetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women.AimsThis study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information.MethodsAn online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women’s knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored.FindingsA large proportion of participants (84.6%; n = 362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%; n = 398), although, 65% (n = 272) were unable to identify the current incidence of stillbirth in Australia.ConclusionWomen who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention.     

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.