The need for improved emotional support: A pilot online survey of Australian women’s access to healthcare services and support at the time of miscarriage

ProblemWomen need improved emotional support from healthcare professionals following miscarriage.BackgroundSignificant psychological morbidity can result following miscarriage and may be exacerbated by poor support experiences. Women frequently report high levels of dissatisfaction with healthcare support at this time.AimThis study was developed to pilot a survey aimed at exploring women’s access to healthcare services and support at the time of miscarriage.MethodsWomen over 18 years, residing in Australia, who had experienced a miscarriage in the past two years completed a 29-item online survey.FindingsA total of 399 women completed the survey. Two key findings arose: 1) More than half of women (59%) were not offered any information about miscarriage or pregnancy loss support organisations or referral/access to counselling services at the time of miscarriage, despite almost all reporting they would have liked various forms of support from items listed 2) More than half (57%) did not receive follow up care, or emotional support at this time, beyond being asked how they were coping emotionally. Other findings showed 3) Women accessed various healthcare services at the time of miscarriage and 4) Women often saw a general practitioner at the time of miscarriage despite having a private obstetrician.ConclusionThere is clear mismatch between the support women want at the time of miscarriage and the care they receive from healthcare professionals. Despite considerable structural barriers, it seems likely there is scope within healthcare professionals’ usual practice for improved support care through simple measures such as increased acknowledgement, information provision and referral to existing support services.     

What women want and why. Women's preferences for induction of labour or expectant management in late-term pregnancy

BackgroundBoth induction of labour at 41 weeks and expectant management until 42 weeks are common management strategies in low-risk pregnancy since there is no consensus on the optimal timing of induction in late-term pregnancy for the prevention of adverse outcomes. Our aim was to explore maternal preference for either strategy and the influence on quality of life and maternal anxiety on this preference.MethodsObstetrical low-risk women with an uncomplicated pregnancy were eligible when they reached a gestational age of 41 weeks. They were asked to fill in questionnaires on quality of life (EQ6D) and anxiety (STAI-state). Reasons of women's preferences for either induction or expectant management were explored in a semi-structured questionnaire containing open ended questions.ResultsOf 782 invited women 604 (77.2%) responded. Induction at 41 weeks was preferred by 44.7% (270/604) women, 42.1% (254/604) preferred expectant management until 42 weeks, while 12.2% (74/604) of women did not have a preference. Women preferring induction reported significantly more problems regarding quality of life and were more anxious than women preferring expectant management (p < 0.001). Main reasons for preferring induction of labour were: “safe feeling” (41.2%), “pregnancy taking too long” (35.4%) and “knowing what to expect” (18.6%). For women preferring expectant management, the main reason was “wish to give birth as natural as possible” (80.3%).ConclusionWomen's preference for induction of labour or a policy of expectant management in late-term pregnancy is influenced by anxiety, quality of life problems (induction), the presence of a wish for natural birth (expectant management), and a variety of additional reasons. This variation in preferences and motivations suggests that there is room for shared decision making in the management of late-term pregnancy.     

Exploring factors contributing to mistreatment of women during childbirth in West Bank,Palestine

BackgroundRespectful care during childbirth is a universal right for each woman in every health system, and mistreatment of women during childbirth is a major breach of this right.AimThis study aimed to explore the views of Palestinian women and healthcare providers regarding factors contributing to the mistreatment of women during childbirth at childbirth facilities in the West Bank, Palestine.MethodsA qualitative study was conducted in the West Bank, Palestine, from February 2019 to April 2019. In-depth interviews were conducted with six Palestinian women and five healthcare providers. Consent was obtained individually from each participant, and the interviews ranged from 40 to 50 min. Data collection was continued until thematic saturation was reached. Open-ended questions were asked during interviews. Thematic analysis was used to interpret the data collected from the interviews.ResultsFour themes were identified with regards to the women and healthcare providers’ views about factors contributing to the mistreatment of women during childbirth in the West Bank, Palestine: limitation in childbirth facilities, factors within the healthcare providers, the women themselves, and barriers within the community.DiscussionMistreatment of women during childbirth may occur due to the limitations of resources and staff in childbirth facilities. Some women also justified the mistreatment, and certain characteristics of the women were believed to be the factors for mistreatment.ConclusionAs the first known study of its kind in West Bank, the identified contributing factors especially the limitations of resources and staff are essential to provide good quality and respectful care at childbirth facilities.     

Large gaps in the quality of healthcare experienced by Swedish mothers during the COVID-19 pandemic: A cross-sectional study based on WHO standards

Background and ProblemExisting healthcare systems have been put under immense pressure during the COVID-19 pandemic. Disruptions in essential maternal and newborn services have come from even high-income countries within the World Health Organization (WHO) European Region.AimTo describe the quality of care during pregnancy and childbirth, as reported by the women themselves, during the COVID-19 pandemic in Sweden, using the WHO ‘Standards for improving quality of maternal and newborn care in health facilities’.MethodsUsing an anonymous, online questionnaire, women ≥18 years were invited to participate if they had given birth in Sweden from March 1, 2020 to June 30, 2021. The quality of maternal and newborn care was measured using 40 questions across four domains: provision of care, experience of care, availability of human/physical resources, and organisational changes due to COVID-19.FindingsOf the 5003 women included, n = 4528 experienced labour. Of these, 46.7% perceived a poorer quality of maternal and newborn care due to the COVID-19. Fundal pressure was applied in 22.2% of instrumental vaginal births, 36.8% received inadequate breastfeeding support and 6.9% reported some form of abuse. Findings were worse in women undergoing prelabour Caesarean section (CS) (n = 475). Multivariate analysis showed significant associations of the quality of maternal and newborn care to year of birth (P < 0.001), parity (P < 0.001), no pharmacological pain relief (P < 0.001), prelabour CS (P < 0.001), emergency CS (P < 0.001) and overall satisfaction (P < 0.001).ConclusionConsiderable gaps over many key quality measures and deviations from women-centred care were noted. Findings were worse in women with prelabour CS. Actions to promote high-quality, evidence-based and respectful care during childbirth for all mothers are urgently needed.     

Health after childbirth: Patterns of reported postpartum morbidity from Lebanon

Problem and backgroundThe postpartum period is under-researched in low and middle income countries. The scarce literature reveals heavy burden of ill health experienced in that period and under utilisation of health services. Understanding the postpartum morbidity burden and identifying the care-seeking behaviours is essential to improve service delivery.QuestionThis paper examines reported postpartum morbidity, care seeking behaviour and whether postpartum morbidity is associated with method of birth.MethodsA cross sectional study of women delivering in 18 private hospitals from two regions in Lebanon was undertaken. Women in their second or third trimester of pregnancy, visiting private obstetric clinics affiliated with participating hospitals were interviewed for baseline information. Reported postpartum morbidity was assessed in an interview conducted at women's homes from 40 days up to six months postpartum.FindingsOf the 269 women recruited, physical postpartum health problems were reported by 93.6% and psychological health problems by 84.4% of women, with more health problems being reported beyond two months postpartum. Women were less likely to seek professional care for psychological health problems. Reporting postpartum health problems was not associated with method of birth.ConclusionA heavy burden of postpartum morbidity is experienced by women with gaps in utilisation of relevant health services. Efforts should be directed towards the organisation and delivery of comprehensive maternity care services.     

Estimating the impact of change in pre-pregnancy body mass index on development of Gestational Diabetes Mellitus: An Australian population-based cohort

BackgroundInternational studies examining maternal overweight and obesity have found GDM risk increases with increasing weight gain between pregnancies.AimThe study aimed to estimate the association between pre-pregnancy maternal body mass index (BMI), change in BMI between pregnancies and Gestational Diabetes Mellitus (GDM) amongst women with consecutive births in an Australian cohort.MethodsWe used a population cohort of women who had at least two consecutive singleton births between 2010 and 2017 in one NSW health district to investigate the risk of GDM in the pregnancy after the index pregnancy, BMI change between pregnancies and the impact of BMI change on risk of GDM.FindingsOf 10,074 women 1987 (16.7%) had no GDM in the index pregnancy but GDM in the subsequent one while 823 (8.2%) had GDM in both pregnancies. No change in BMI between pregnancies occurred in 47% of women, while 12% had a decrease and 41% an increase. After adjusting for socio-demographic characteristics and selected maternal and perinatal confounders, a reduction in BMI between births in women without GDM in the index pregnancy was associated with a 36% lower risk in GDM (aRR: 0.64; 95% CI: 0.49?0.85), while an increase in BMI was associated with increased risk of GDM with the greatest risk amongst those who gained 4+ kg/m² (aRR 2.27; 95%CI: 1.88–2.75).ConclusionInterpregnancy weight change is an important modifiable risk factor for the risk of GDM in a subsequent pregnancy. Clinical guidelines and health messages about interpregnancy weight change are important for all women.     

The cost of vaginal birth at home,in a birth centre or in a hospital setting in New South Wales: A micro-costing study

BackgroundWomen want greater choice of place of birth in New South Wales, Australia. It is perceived to be more costly to health services for women with a healthy pregnancy to give birth at home or in a birth centre. It is not known how much it costs the health service to provide care for women planning to give birth in these settings.AimThe aim of this study was to determine the direct cost of giving birth vaginally at home, in a birth centre or in a hospital for women at low risk of complications, in New South Wales.MethodsA micro-costing design was used. Observational (time and motion) and resource use data collection was undertaken to identify the staff time and resources required to provide care in a public hospital, birth centre or at home for women with a healthy pregnancy.FindingsThe median cost of providing care for women who plan to give birth at home, in a birth centre and in a hospital were similar (AUD $2150.07, $2100.59 and $2097.30 respectively). Midwifery time was the largest contributor to the cost of birth at home, and overhead costs accounted for over half of the total cost of BC and hospital birth. The cost of consumables was low in all three settings.ConclusionIn this study, we have found there is little difference in the cost to the health service when a woman has an uncomplicated vaginal birth at home, in a birth centre or in a hospital setting.     

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.     

Prevalence of and risk factors associated with cesarean section in Lebanon — A retrospective study based on a sample of 29,270 women

Background

During the last decades, there has been an alarming and dramatic increase in the number of cesarean births in both developed and undeveloped countries. This increase has not been clinically justified but, nevertheless, has raised an important number of issues.

Tobacco use in the third trimester of pregnancy and its relationship to birth weight. A prospective study in Spain

BackgroundFew studies have been carried out in Spain examining the use of tobacco amongst expectant mothers and its effect on birth weight.AimsTo observe the proportion of expectant mothers who smoke during their pregnancy, and the impact of tobacco consumption on maternal and birth weight. We also aimed to identify the trimester of pregnancy in which tobacco use produced the greatest reduction in birth weight.MethodsProspective observational study in Spain. A random sampling strategy was used to select health centres and participant women. A total of 137 individuals were enrolled in the study. Exposure to tobacco was measured through a self-reported questionnaire. Regressions were performed to obtain a predictive model for birth weight related to smoking.FindingsOverall, 35% of study participants were smokers during the pre-gestational period (27% in the first trimester, 21.9% in the second and 21.2% in the third). 38.7% of smoking cessation attempts took place in the third-trimester. Pregnant women who smoked up to the third trimester had a higher risk of giving birth to a baby under 3000 g, compared to non-smokers (OR = 5.94, CI 95%: 1.94–18.16). Each additional unit of tobacco consumed daily in the 3rd trimester led to a 32 g reduction in birth weight.ConclusionAn important proportion of pregnant women in Spain smoke during pregnancy. Pregnant women exposed to tobacco have newborns with lower birth weight. Smoking during the 3rd trimester of pregnancy is associated with the greatest risk of lower birth weight.     

Developing a clinical care pathway for obese pregnant women: A quality improvement project

ProblemObesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) ≥30 kg/m², defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted.AimTo plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI ≥ 35 kg/m² at their first antenatal visit.Project settingThe project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia.SubjectsEighty-two women with a BMI ≥ 35 kg/m² were eligible for the alternative care pathway, offered between January and December 2010.InterventionThe alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation.FindingsDespite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening.     

Chinese obstetricians’ attitudes,beliefs, and clinical practices related to cesarean delivery on maternal request.

BackgroundObstetricians’ beliefs, attitudes, and clinical practices related to cesarean delivery on maternal request appears particularly important in the context of high cesarean section rate. However, few relative studies have been conducted.AimTo examine Chinese obstetricians’ attitudes, beliefs, and clinical practices with regard to cesarean delivery on maternal request, and to explore influencing factors associated with their practices of cesarean delivery on maternal request.MethodsA cross-sectional design was used. Self-administered anonymous questionnaires were distributed to eligible obstetricians at the Congress of the Shanxi Society of Gynecology and Obstetrics as well as the Congress of the Hainan Society of Gynecology and Obstetrics. The overall response rate was 526/649 (81.05%). Multivariate logistic regression models were used to examine independent effects on obstetrician’s clinical practices related to cesarean delivery on maternal request.FindingsObstetricians who agreed with pregnant women’s decision to choose cesarean section directly and believed the benefits of this procedure outweigh the risks had higher odds of performing cesarean delivery on maternal request. In addition, measures to decrease cesarean section at hospitals were associated with reduced likelihood to perform cesarean delivery on maternal request.ConclusionsThe present study showed a strong correlation between obstetricians’ attitudes, beliefs, as well as interventions to decrease cesarean section at hospitals and their clinical practices of cesarean delivery on maternal request. Measures to enhance the training of obstetricians and reduce CS at hospitals are essential to decrease the overall cesarean section rate in China.     

Gestational weight gain counselling gaps as perceived by pregnant women and new mothers: Findings from the electronic maternal health survey

ProblemToo much or too little gestational weight gain (GWG) can negatively impact maternal and fetal health, according to Institute of Medicine Guidelines.BackgroundHealth care providers are key players in providing reliable evidence-informed prenatal advice related to appropriate GWG. However, there appears to be inconsistent GWG communication among healthcare providers during prenatal care.AimTo determine pregnant women and new mothers’ perceptions of healthcare provider GWG and dietary counselling during the pregnancy period.MethodsA reliable and validated cross-sectional electronic survey was administered to currently pregnant women and women who had recently given birth. The web-based questionnaire was self-administered and took 10–25 min.FindingsA total of 1507 eligible women participated in the survey. More than half (57%) reported that their healthcare provider talked to them about personal weight gain limits. Of these participants, about a third (34%) of participants were counselled regularly at each or most visits. Among the women that were not counselled on personal GWG limits, over half (56%) reported that healthcare provider guidance would have been helpful to achieve their target weight. Less than half (45%) of participants reported that their healthcare providers discussed dietary requirements or changes in pregnancy.DiscussionThese findings highlight areas for improvement in prenatal dialogue, which can support better outcomes for both mother and baby.ConclusionA better understanding of pregnant and mothers’ perceptions about weight and diet counselling is needed to understand what may need greater attention and clarification and to improve such dialogue.     

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.     

Perspectives on antenatal education associated with pregnancy outcomes: Systematic review and meta-analysis

BackgroundMany studies on the relation between maternal health and infant health, including the effect of structured antenatal education, have been published and expanded over the years.AimInvestigate the impact of various antenatal education programmes on pregnancy outcomes to aid the development of future guidelines related to maternal and foetal health.MethodsBibliographic databases (Cochrane, PubMed, EMBASE, CINAHL, Korean Studies Information Service System) were searched up to November 2018, following the PICO criteria: population (pregnant women), intervention (antenatal education), comparison (not specified), and outcome (maternal and foetal outcome including physical or mental health components).FindingsWe included 23 eligible studies consisting of 14 controlled trials and 9 observational studies. The maternal physical outcomes depending on participation in antenatal education were not significantly different; however, the caesarean birth rate was lower in the antenatal education group (relative risk, RR, 0.90; 95% confidence interval, CI, 0.82–0.99), as was the use of epidural anaesthesia (RR, 0.84; 95% CI, 0.74–0.96). The maternal mental health outcomes of stress and self-efficacy significantly improved in the antenatal education group, although there was no difference in anxiety and depression. The foetal outcomes of birth weight or gestational age at birth were also not different between the groups.ConclusionAntenatal education can reduce maternal stress, improve self-efficacy, lower the caesarean birth rate, and decrease the use of epidural anaesthesia; however, there is limited evidence of its effects on maternal or foetal physical outcomes. Therefore, antenatal education should be standardised to elucidate its actual mental and physical health effects.     

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.     

The impacts of the COVID-19 pandemic on birth satisfaction in a prospective cohort of 2,341 U.S. women

ProblemBirth satisfaction is an important health outcome that is related to postpartum mood, infant caretaking, and future pregnancy intention.BackgroundThe COVID-19 pandemic profoundly affected antenatal care and intrapartum practices that may reduce birth satisfaction.AimTo investigate the extent to which pandemic-related factors predicted lower birth satisfaction.Methods2341 women who were recruited prenatally in April–May 2020 and reported a live birth between April–October 2020 were included in the current analysis. Hierarchical linear regression to predict birth satisfaction from well-established predictors of birth satisfaction (step 1) and from pandemic-related factors (step 2) was conducted. Additionally, the indirect associations of pandemic-related stress with birth satisfaction were investigated.FindingsThe first step of the regression explained 35% of variance in birth satisfaction. In the second step, pandemic-related factors explained an additional 3% of variance in birth satisfaction. Maternal stress about feeling unprepared for birth due to the pandemic and restrictions on companions during birth independently predicted lower birth satisfaction beyond the non-pandemic variables. Pandemic-related unpreparedness stress was associated with more medicalized birth and greater incongruence with birth preference, thus also indirectly influencing birth satisfaction through a mediation process.DiscussionWell-established contributors to birth satisfaction remained potent during the pandemic. In addition, maternal stress and restriction on accompaniment to birth were associated with a small but significant reduction in birth satisfaction.ConclusionStudy findings suggest that helping women set flexible and reasonable expectations for birth and allowing at least one intrapartum support person can improve birth satisfaction.