Opportunities for enhancing pregnancy planning and preconception health behaviours of Australian women

Problem and backgroundThe preconception period provides a significant opportunity to engage women in healthy behaviour change for improved maternal and child health outcomes. However, there is limited research exploring women’s pregnancy planning in Australia.AimThis study investigated associations between pregnancy planning, socio-demographics and preconception health behaviours in Australian women.MethodsA retrospective cross-sectional survey of pregnant women ≥18-years-of-age recruited through a Victorian public maternity service and a national private health insurer.ResultsOverall 317 women (30 ± 4.7 years) participated (public: n = 225, private: n = 92). Planned pregnancies were reported by 74% of women and were independently associated with marital status (AOR = 5.71 95% CI 1.92–17.00, p = 0.002); having ≤2 children (AOR = 3.75 95% CI 1.28–11.05, p = 0.016); and having private health insurance (AOR = 2.51 95% CI 1.08–5.81, p = 0.03). Overall, women reported preconception: any folic-acid supplementation (59%), up-to-date cervical screening (68%), weight management attempts (75%), accessing information from health professionals (57%) and immunisation reviews (47%). Pregnancy planners were more likely to use folic-acid (AOR = 17.13 95% CI 7.67–38.26, p < 0.001), review immunisations (AOR = 2.09 95% CI 1.07–4.10, p = 0.03) and access information (AOR = 3.24 95% CI 1.75–6.00, p < 0.001) compared to non-planners. Women <25-years-of-age were less likely to access information (AOR = 0.38 95% CI 0.16–0.89, p = 0.03) and take folic-acid (AOR = 0.23 95% CI 0.09–0.59, p = 0.002) and were more likely to smoke 3-months preconception (AOR = 6.68 95% CI 1.24–36.12, p = 0.03).ConclusionsWomen with planned and unplanned pregnancies reported variable preconception health behaviour uptake and limited healthcare engagement. Opportunities exist to improve awareness and healthcare engagement for optimising preconception health and pregnancy planning benefits including collaborative health promotion. Population-based and targeted approaches reaching pregnancy planners and non-planners are required.     

An exploration of Australian midwives’ knowledge of intimate partner violence against women during pregnancy

BackgroundIntimate partner violence is recognised as a global public health issue. Living with intimate partner violence results in poorer health status with reduced quality of life and higher utilisation of health services. Increased awareness, education and training, and an understanding of multi-agency collaboration are vital in order for health practitioners to respond to women experiencing partner violence and abuse. Midwives are well placed to identify, provide immediate support, and refer women onto appropriate support agencies but may lack appropriate education, training or support.AimTo investigate midwives’ knowledge of intimate partner violence against women during pregnancy.MethodsAn online survey link was distributed through the Australian College of Midwives. The survey included personal, professional and practice details, and 25 questions that tested knowledge about intimate partner violence.Findings152 midwives completed the online questionnaire. Knowledge scores ranged from 27 to 48 (out of a possible 50), with the mean total score of 42.8 (SD = 3.3). Although 60% of participants scored 48, two-thirds did not know about the risks and signs of intimate partner violence. One-third of the midwives did not know about age risks associated with intimate partner violence. Around 25% incorrectly believed that perpetrators are violent because of alcohol or drug use. Nearly 90% (88%) of participants had some education or training about intimate partner violence. Those with some training achieved higher knowledge scores than those with no formal training (Mann–Whitney U = 1272, p = 0.003).ConclusionParticipating midwives generally reported a high level of knowledge about intimate partner violence but held misconceptions about risks and characteristics of perpetrators of violence. These knowledge gaps may adversely affect their ability to identify women at risk of violence. Education about intimate partner violence was associated with improved knowledge. Future training and education on intimate partner violence should target identified knowledge gaps.     

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.     

The impact of routine assessment of past or current mental health on help-seeking in the perinatal period

BackgroundClinical practice guidelines now recommend that women be asked about their past or current mental health as a routine component of maternity care. However, the value of this line of enquiry in increasing engagement with support services, as required, remains controversial.AimThe current study aimed to examine whether assessment of past or current mental health, received with or without referral for additional support, is associated with help-seeking during pregnancy and the postpartum.MethodsA subsample of women drawn from the Australian Longitudinal Study on Women's Health (young cohort) who reported experiencing significant emotional distress during pregnancy (N = 398) or in the 12 months following birth (N = 380) participated in the study.ResultsMultivariate analysis showed that women who were not asked about their emotional health were less likely to seek any formal help during both pregnancy (adjOR = 0.09, 95%CI: 0.04–0.24) and the postpartum (adjOR = 0.07, 95%CI: 0.02–0.13), as were women who were asked about these issues but who were not referred for additional support (antenatal: adjOR = 0.26, 95%CI: 0.15–0.45; postnatal: adjOR = 0.14, 95%CI: 0.07–0.27). However, considerable levels of consultation with general practitioners, midwives and child health nurses, even in the absence of referral, were evident.ConclusionThis study demonstrates that enquiry by a health professional about women's past or current mental health is associated with help-seeking throughout the perinatal period. The clinical and resource implications of these findings for the primary health care sector should be considered prior to the implementation of future routine perinatal depression screening or psychosocial assessment programmes.     

Impact of having a high-risk pregnancy on future postpartum contraceptive method choice

BackgroundTo compare the knowledge and preference of preconceptional contraception to future postpartum contraceptive method choice in high-risk pregnancies.Research questionDoes a high-risk pregnancy condition affect future postpartum contraceptive method choice?MethodWomen hospitalised at the High Risk Pregnancy unit of a tertiary research and training hospital were asked to complete a self-reported questionnaire that included demographic characteristics, presence of unintended pregnancy, contraceptive method of choice before the current pregnancy, plans for contraceptive use following delivery and requests for any contraceptive counselling in the postpartum period.FindingsA total of 655 pregnant women were recruited. The mean age, gravidity and parity of the women were 27.48 ± 6.25 years, 2.81 ± 2.15 and 1.40 ± 1.77, respectively. High-risk pregnancy indications included 207 (31.6%) maternal, 396 (60.5%) foetal and 52 (7.9%) uterine factors. All postpartum contraceptive choices except for combined oral contraceptives (COCs) usage were significantly different from preconceptional contraceptive preferences (p < 0.001). High-risk pregnancy indications, future child bearing, ideal number of children, income and education levels were the most important factors influencing postpartum contraceptive choices. While the leading contraceptive method in the postpartum period was long-acting reversible contraceptive methods (non-hormonal copper intrauterine device Cu-IUD, the levonorgestrel-releasing intrauterine system (LNG-IUS) (40%), the least preferred method was COCs use (5.2%) and preference of COCs use showed no difference between the preconceptional and postpartum periods (p = 0.202). Overall 73.7% of the women wanted to receive contraceptive counselling before their discharge.ConclusionA high-risk pregnancy condition may change the opinion and preference of contraceptive use, and also seems to affect the awareness of family planning methods.     

The profile of women who consult midwives in Australia

BackgroundThere is no Australian data on the characteristics of women who consult with midwives.AimTo determine the profile of women who consult midwives in Australia.MethodsThis cross-sectional research was conducted as part of the Australian Longitudinal Study on Women's Health (ALSWH). Participants were the younger (31–36 years) cohort of the ALSWH who completed a survey in 2009, and indicated that they were currently pregnant (n = 801). The main outcome measure was consultation with a midwife.FindingsOf the 801 women who indicated that they were currently pregnant at the time of the survey, 19%, 42%, and 70% of women in the first, second and third trimesters respectively had consulted with a midwife. Women were more likely to consult a midwife if they: also consulted with a hospital doctor (OR = 2.70, 95% CI: 1.66, 4.40); also consulted with a complementary and alternative medicine practitioner (OR = 1.94, 95% CI: 1.25, 3.03); were depressed (OR = 1.84, 95% CI: 1.03, 3.28); constipated (OR = 1.80, 95% CI: 1.04, 3.13); or had been diagnosed or treated for hypertension during pregnancy (OR = 2.78, 95% CI: 1.27, 6.09). Women were less likely (OR = 0.34, 95% CI: 0.21, 0.56) to consult with a midwife if they had private health insurance.ConclusionWomen were more likely to consult with midwives in conjunction with consultations with hospital doctors or complementary and alternative medicine practitioners. Women with private health insurance were less likely to consult midwives. More research is necessary to determine the implications of the lack of midwifery care for these women.     

Midwives’ self-reported knowledge and skills to assess and promote maternal health literacy: A national cross-sectional survey

BackgroundLittle is known about midwives’ knowledge and skills to assess and promote maternal health literacy.AimsTo test the reliability and validity of a new tool to assess midwives’ health literacy knowledge, skills and attitudes.MethodsUsing a cross-sectional design, midwives were recruited through professional and social media networks. The online survey included demographic and professional questions and a new measure on midwives’ health literacy knowledge, skills and attitudes. Convergent validity was assessed using ten items from the Caring Assessment Scale. Perceived barriers to promoting maternal health literacy were sought.FindingsThree hundred and seven participants completed the survey. A two-factor solution accounted for 41% of variance and resulted in 14 items, including all attitude items, being removed. Cronbach’s alpha reliability was acceptable (Skills = .76; Knowledge = .66). Convergent validity was established. Most midwives (77.1%, n = 221) reported giving limited attention to formally assessing women’s health literacy. Between 30 to 60% of midwives never or only sometimes used specific techniques to promote maternal health literacy. Most (75%, n = 201) had not received education about health literacy.Discussion and ConclusionsThe new Transforming Maternity Care Collaborative Health Literacy tool was valid and reliable. Few midwives formally assessed or promoted women’s health literacy. Midwives require education about maternal health literacy assessment and promotion to ensure women understand information being conveyed. A large national survey of midwives using the new tool is recommended.     

Health professionals’ perceptions of a midwifery model of woman-centred care implemented on a hospital labour ward

BackgroundTheoretical models as a basis for midwives’ care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts.AimTo explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals.MethodsData were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n = 16), obstetricians (n = 8), assistant nurses (n = 11) and managers (n = 8). The text from interviews was analysed using content analysis.FindingsFrom expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses.DiscussionClarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management.ConclusionsThe model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.     

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.     

Cross sectional study of Australian midwives knowledge and use of sterile water injections for pain relief in labour

BackgroundThe effectiveness of sterile water injections (SWI) to relieve back pain in labour is supported by a number of randomised controlled trials. Although the procedure is available in a number of Australian maternity units, there is no information regarding the use of SWI by midwives, in terms of knowledge and availability, clinical application or technique used. Neither is there any data on midwives who do not use SWI nor the specific challengers and barriers encountered by midwives introducing SWI.MethodAn invitation to participate in an online survey was emailed to 4700 members of the Australian College of Midwives (ACM) and 484 members of CRANAplus (Remote Health Organisation). Nine hundred and seventy midwives completed the survey (19%).ResultsFour hundred and seven (42.5%) midwives currently used SWI in their practice and five hundred and fifty-one (57.5%) indicated they did not. Eighty-six percent (n = 478/548) indicated they would consider using SWI and 90% (n = 500/547) were interested in obtaining further information about SWI. The main reasons cited for not using SWI was the lack of a policy or guideline (n = 271, 57.5%) and being unable to access workshops or resource material (n = 68, 14.4%).ConclusionThis study indicates that SWI is not being used by the majority of midwives participating in the study, although there is a strong desire by midwives to learn about and explore its use. Greater access to information and workshops on SWI is highlighted. In response to the findings of this survey the authors are currently developing an online resource and training to support units to introduce SWI.     

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.     

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.     

The views and attitudes of health professionals providing antenatal care to women with a high BMI: A qualitative research study

BackgroundThe prevalence of overweight and obesity is increasing amongst women of child bearing age. The objective of this study was to investigate the views and attitudes of providers of antenatal care for women who have a body mass index (BMI) of 30 kg/m² and over.MethodsA qualitative study using focus groups was undertaken within the department of obstetrics and gynaecology at a large teaching hospital in south-eastern Australia. Three focus group discussions were held. One with hospital midwives (n = 10), one with continuity of care midwives (n = 18) and one with obstetricians (n = 5). Data were analysed using Interpretative Phenomenological Analysis (IPA).FindingsSix dominant themes emerged: (1) obesity puts the health of mothers, babies and health professionals at risk; (2) overweight and obesity has become the norm; (3) weighing women and advising about weight gain is out of fashion; (4) weight is a sensitive topic to discuss; (5) there are significant barriers to weight control in pregnancy; and (6) health professionals and women need to deal with maternal obesity. These themes are drawn together to form a model representing current health care issues for these women.ConclusionHealth professionals, who have a high BMI, can find it difficult to discuss obesity during antenatal visits with obese women. Specialist dietary interventions and evidence based guidelines for working with child-bearing women is seen as a public health priority by health care professionals.     

Outcome evaluation of an educational program for Japanese midwives to promote breast awareness for women

AimThe objective of this study was to evaluate educational approaches for midwives to promote breast awareness for postnatal women by measuring the knowledge, attitude and practice of midwives.MethodsA nonequivalent control design comparing two intervention groups and control group was used. Participants were Japanese midwives agreeing to this study. Midwives in the program group attended the program; those in the text group only read the textbook. Midwives in the control group neither attended the program nor learned by textbook. All measurements were administered at baseline, one-month post-program, and three-month post-program.ResultsAmong 215 participants, 168 midwives (45 program, 62 text, and 61 control) remained until three month follow-up. The knowledge test score was found to have significant mutual interactions between the three groups and time (F = 14.2, df = 4, p < 0.001). However, the attitudes did not differ between the three groups. Implementation rates for midwifery practice incorporating breast awareness education for postpartum women were different at one month and three months between the three groups. Implementation of breast awareness education at three months revealed the following factors: program group (OR 5.4, 95%CI [1.3–21.8]; text group: OR 0.7, 95%CI [0.2–2.7]) and implementation of breast awareness education at the first time measurement (OR 18.6, 95%CI [4.6–73.9]).ConclusionsThe results of this study showed that the educational program increased midwives’ knowledge and contributed to the continuation implementing breast awareness education for postpartum women about three months after testing.     

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.