Induction of labour indications and timing: A systematic analysis of clinical guidelines

BackgroundThere is widespread and some unexplained variation in induction of labour rates between hospitals. Some practice variation may stem from variability in clinical guidelines. This review aimed to identify to what extent induction of labour guidelines provide consistent recommendations in relation to reasons for, and timing of, induction of labour and ascertain whether inconsistencies can be explained by variability guideline quality.MethodWe conducted a systematic search of national and international English-language guidelines published between 2008 and 2018. General induction of labour guidelines and condition-specific guidelines containing induction of labour recommendations were searched. Guidelines were reviewed and extracted independently by two reviewers. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II Instrument.FindingsForty nine guidelines of varying quality were included. Indications where guidelines had mostly consistent advice included prolonged pregnancy (induction between 41 and 42 weeks), preterm premature rupture of membranes, and term preeclampsia (induction when preeclampsia diagnosed ≥37 weeks). Guidelines were also consistent in agreeing on decreased fetal movements and oligohydramnios as valid indications for induction, although timing recommendations were absent or inconsistent. Common indications where there was little consensus on validity and/or timing of induction included gestational diabetes, fetal macrosomia, elevated maternal body mass index, and twin pregnancy.ConclusionSubstantial variation in clinical practice guidelines for indications for induction exists. As guidelines rated of similar quality presented conflicting recommendations, guideline variability was not explained by guideline quality. Guideline variability may partly account for unexplained variation in induction of labour rates.     

Women’s experiences of decision-making and attitudes in relation to induction of labour: A survey study

BackgroundRates of induction of labour have been increasing globally to up to one in three pregnancies in many high-income countries. Although guidelines around induction, and strength of the underlying evidence, vary considerably by indication, shared decision-making is increasingly recognised as key. The aim of this study was to identify women’s mode of birth preferences and experiences of shared decision-making for induction of labour.MethodAn antenatal survey of women booked for an induction at eight Sydney hospitals was conducted. A bespoke questionnaire was created assessing women’s demographics, indication for induction, pregnancy model of care, initial birth preferences, and their experience of the decision-making process.ResultsOf 189 survey respondents (58% nulliparous), major reported reasons for induction included prolonged pregnancy (38%), diabetes (25%), and suspected fetal growth restriction (8%). Most respondents (72%) had hoped to labour spontaneously. Major findings included 19% of women not feeling like they had a choice about induction of labour, 26% not feeling adequately informed (or uncertain if informed), 17% not being given alternatives, and 30% not receiving any written information on induction of labour. Qualitative responses highlight a desire of women to be more actively involved in decision-making.ConclusionA substantial minority of women did not feel adequately informed or prepared, and indicated they were not given alternatives to induction. Suggested improvements include for face-to-face discussions to be supplemented with written information, and for shared decision-making interventions, such as the introduction of decision aids and training, to be implemented and evaluated.     

Exploring unwarranted clinical variation: The attitudes of midwives and obstetric medical staff regarding induction of labour and planned caesarean section

BackgroundUnexplained clinical variation is a major issue in planned birth i.e. induction of labour and planned caesarean section.AimTo map attitudes and knowledge of maternity care professionals regarding indications for planned birth, and assess inter-professional (midwifery versus medical) and intra-professional variation.MethodsA custom-created survey of medical and midwifery staff at eight Sydney hospitals. Staff were asked to rate their level of agreement with 45 “evidence-based” statements regarding caesareans and inductions on a five-point Likert scale. Responses were grouped by profession, and comparisons made of inter- and intra-professional responses.FindingsTotal 275 respondents, 78% midwifery and 21% medical. Considerable inter- and intra-professional variation was noted, with midwives generally less likely to consider any of the planned birth indications “valid” compared to medical staff. Indications for induction with most variation in midwifery responses included maternal characteristics (age≥40, obesity, ethnicity) and fetal macrosomia; and for medical personnel in-vitro fertilisation, maternal request, and routine induction at 39 weeks gestation. Indications for caesarean with most variation in midwifery responses included previous lower segment caesarean section, previous shoulder dystocia, and uncomplicated breech; and for medical personnel uncomplicated dichorionic twins. Indications with most inter-professional variation were induction at 41+ weeks versus 42+ weeks and cesarean for previous lower segment caesarean section.DiscussionBoth inter- and intra-professional variation in what were considered valid indications reflected inconsistency in underlying evidence and/or guidelines.ConclusionGreater focus on interdisciplinary education and consensus, as well as on shared decision-making with women, may be helpful in resolving these tensions.     

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.     

Born in another country: Women's experience of labour and birth in Queensland,Australia

BackgroundWomen born outside Australia make up more than a fifth of the Queensland birthing population and like migrants in other parts of the world face the challenges of cultural dislocation and possible language barriers. Recognising that labour and birth are major life events the aim was to investigate the experiences of these women in comparison to native-born English speaking women.MethodsSecondary analysis of data from a population based survey of women who had recently birthed in Queensland. Self-reported clinical outcomes and quality of interpersonal care of 481 women born outside Australia who spoke a language other than English at home were compared with those of 5569 Australian born women speaking only English.ResultsAfter adjustment for demographic factors and type of birthing facility, women born in another country were less likely to be induced, but more likely to have constant electronic fetal monitoring (EFM), to give birth lying on their back or side, and to have an episiotomy. Most women felt that they were treated as an individual and with kindness and respect. However, women born outside Australia were less likely to report being looked after ‘very well’ during labour and birth and to be more critical of some aspects of care.ConclusionIn comparing the labour and birth experiences of women born outside the country who spoke another language with native-born English speaking women, the present study presents a largely positive picture. However, there were some marked differences in both clinical and interpersonal aspects of care.     

Pregnancy nutrition knowledge and experiences of pregnant women and antenatal care clinicians: A mixed methods approach

Background

Dietary intake of pregnant women do not appear to meet the dietary recommendations. Nutrition knowledge and practices of pregnant women and their antenatal care clinicians are factors that may be influential on dietary intakes of pregnant women.

The influence of the birthplace and models of care on midwifery practice for the management of women in labour

This paper will examine how the settings in which midwives practice (the birthplace) and models of care affect midwives’ decision making during the management of labour. One-hundred-and-four independent, team and hospital based midwives and 100 low obstetric risk nulliparous women to whom labour care was provided were surveyed. These midwives and women resided in the Auckland metropolitan area of New Zealand. The majority of midwives who participated worked in models of care which provided women with continuity of carer and care, however, this was not found to influence the way the midwives provided labour care. Instead, practice was found to be relatively homogenous regardless of whether the midwives worked in independent, team, or hospital-based practice. The birthplace setting in which the labour care took place did influence midwifery practice. The majority of midwives provided labour care in large obstetric hospitals and identified practices dominated by the medical model of care. Practice was described as being influenced by intervention and the need for technology, however, this did not prevent the majority of women from perceiving they were actively involved in the decision making process and that they worked in partnership with their midwives. Closer examination of the midwives’ decision making processes whilst providing the labour care revealed that the midwives’ individual decisions were influenced by the needs of the women rather than the hospital protocols. What became evident was that the midwives in this study had adopted a humanistic approach to care whereby technology was used alongside relationship-centred care.     

Comparing compliance with commencement and use of two partograph designs for women in active labour: A randomised controlled trial

BackgroundDocumentation and assessment of progress in labour using a partograph is recommended by the World Health Organisation to assist in the timely recognition of labour dystocia. Recent studies have tested new designs of partographs that aim to account for more variable rates of labour progress. However, other studies have suggested that poor compliance in the completion of partographs affects utility. The objective of this study was to compare two types of partographs for compliance in documentation and use for managing labour.MethodsLow-risk nulliparous women in spontaneous labour (n = 228) were randomised to either an Action Line (control) (n = 114) or Dystocia Line partograph (intervention) (n = 114). Primary outcome was compliance with instructions for commencement of the partograph following a multifaceted training strategy. Secondary outcomes included compliance with the accompanying clinical management protocol for each partograph; and labour and birth outcomes.ResultsThe compliance rate for commencing the Action line partograph was 43.2% compared to 67.0% (p = 0.02) for the Dystocia line partograph. Other than a reduction in artificial rupture of membranes in the Dystocia Line group there were no other differences in labour management or birth outcomes. The use of centralised electronic display of labour progress may be a contributing factor.ConclusionsCompliance with the commencement and use of either partograph was low. There was little indication that the partograph was being utilized in the assessment and management of prolonged labour. Further studies are needed to explore the current utility of partographs in labour management and the effect of centralised monitoring of progress in high resource settings     

Role of women in schooling and child labour decision: the case of urban boys in India

This paper uses household level data from National Sample Survey Organization (NSSO) of India, the 55th round (1999–2000), to show that for urban male children there exists significant wage incentive for schooling, though school dropout rate and child labour incidence are not so small. The parents’ level of education plays an important role in reducing this tendency; thus establishing the linkage between social and human capital outcomes in the family. We also look at the incidence of harmful and manual occupations among the child labour. Mother’s education now appears as a very important factor in curbing these incidences; supporting earlier findings that women’s empowerment (one important indicator of which would be female educational level) is indeed instrumental in increasing parental awareness.     

Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone,Amhara regional state,Ethiopia: A quasi-experimental study

BackgroundIn a low-resource setting, information on the effect of midwife-led continuity of care (MLCC) is limited. Therefore, this study aimed to determine the effect of MLCC on maternal and neonatal health outcomes in the Ethiopian context.MethodA study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals of the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low risk women were allocated to one of two groups; the midwife-led continuity of care (MLCC or intervention group) (received all antenatal, labour, birth, and immediate postnatal care from a single midwife or backup midwife) (n = 589) and the Shared model of care (SMC or comparison group) (received care from different staff members at different times) (n = 589). The two outcomes studied were Spontaneous vaginal birth and preterm birth. Outcome variables were compared using multivariate generalized linear models (GLMs) and reported using adjusted risk ratios (aRR) with 95% confidence intervals.FindingsWomen in MLCC were, in comparison with women in the SMC group more likely to have spontaneous vaginal birth (aRR of 1.198 (95% CI 1.101–1.303)). Neonates of women in MLCC were in comparison with those in SMC less likely to be preterm (aRR of 0.394; 95% CI (0.227–0.683)).ConclusionIn this study, use of the MLCC model improved maternal and neonatal health outcomes. To scale up and further investigate the effect and feasibility of this model in a low resource setting could be of considerable importance in Ethiopia and other Sub-Saharan Africa countries.     

A Decision Aid for midwifery continuity of care: Development and pilot acceptability testing

BackgroundMany maternity services in Australia offer women a variety of models of care including midwife led models. Childbearing women, however, need to understand the differences between these models if they are to make an informed decision about their choice of care. Decision Aids (DA) help people decide when there is not a single best option and the best decision will be based upon the values of the decision maker. There is no current tool that focuses on the choice of midwife led vs other models of maternity care.AimThis research aimed to develop, and pilot test a Decision Aid focusing on the choice between midwife led and standard models of maternity care.MethodsThe DA was developed using the International Patient Decision Aid Standards and pilot tested for acceptability with a group of clinicians who provide antenatal care in one jurisdiction in Australia. A posttest only study was conducted assessing knowledge, acceptability and decisional conflict, with a group of women of childbearing age living in the jurisdiction.FindingsA DA was developed and pilot acceptability testing with 14 women and 13 clinicians of Australian Capital Territory (ACT) health demonstrated its acceptability and highlighting areas for further development.DiscussionSome revisions may be needed to address issues of balance and bias toward midwife-led care identified by some recipients.ConclusionPilot acceptability testing with women and staff of ACT health provides a steppingstone to further research, development and evaluation of this DA.     

Emotional labour and aboriginal maternal infant care workers: The invisible load

Background

The term ‘emotional labour’ has been used to describe the competing demands on midwives to empathize with clients whilst maintaining a level of professional detachment. Previous research indicates that when individuals experience difficulty managing these emotions, burnout may result. Aboriginal health care workers often have roles with large emotional demands, as they are relied upon heavily to engage clients in care. However, the concept of emotional labour has received little attention in relation to this group.

Trends and characteristics of women undergoing induction of labour in a tertiary hospital setting: A cross-sectional study

BackgroundIn many well-resourced countries, rising rates of intervention are being observed during pregnancy, labour and childbirth with induction of labour (IOL) fast becoming one of the most common. In Australia, the rate of induction of labour has increased by over 30% since 2007, and today one in three women have their labours induced. We do not however have a good understanding of the contribution of specific obstetric populations to this trend.MethodsWe examine the contribution of specific obstetric populations to induction of labour over a six-year period at one tertiary maternity service, using the Nippita classification system. Average Annual Percentage Changes (AAPC) were calculated along with 95% confidence intervals and P values set at 0.05.ResultsThe overall rate of induction of labour increased from 21.3% in 2012 to 30.9% in 2017, representing an Average Annual Percent Change of 8.1, P < 0.0001 (95% CI 7–9.6). The greatest AAPC was seen in group 5 (parous, no previous caesarean section, 39–40 weeks, single cephalic), followed by group 2 (nulliparous, 39–40 weeks, single cephalic) and 1 (nulliparous, 37–38 weeks, single cephalic).ConclusionsThe use of the Nippita classification system allowed for standardised comparison across timepoints, facilitating identification of the subpopulations driving changes in rates of induction of labour. Rates of induction of labour saw a year on year increase which in this maternity service, it is not being driven by post-dates pregnancies. Further work is required to understand the role of other potential contributors such as diabetes.     

Differences in labour force participation by motherhood status among second-generation Turkish and majority women across Europe

Second-generation Turkish immigrants make up an increasingly important segment of European labour markets. These young adults are entering the prime working ages and forming families. However, we have only a limited understanding of the relationship between labour force participation and parenthood among second-generation Turkish women. Using unique data from the Integration of the European Second Generation survey (2007/08), we compared the labour force participation of second-generation Turkish women with their majority-group counterparts by motherhood status in four countries. We found evidence that motherhood gaps, with respect to labour force participation, were similar for majority and second-generation Turkish women in Germany and in Sweden; however, there may be larger gaps for second-generation mothers than for majority women in the Netherlands and France. Cross-national findings were consistent with the view that national normative and social policy contexts are relevant for the labour force participation of all women, regardless of migrant background.     

Models of midwifery care for Indigenous women and babies: A meta-synthesis

Issue

Indigenous women in many countries experience a lack of access to culturally appropriate midwifery services. A number of models of care have been established to provide services to women. Research has examined some services, but there has not been a synthesis of qualitative studies of the models of care to help guide practice development and innovations.

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review

BackgroundAll women require access to quality maternity care. Continuity of midwifery care can enhance women’s experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities.AimTo explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia.MethodsThis integrative review used Whittemore and Knafl’s approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools.FindingsFourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: ‘Contributing to safe processes and outcomes’, ‘Building relational trust’, and ‘Collaborating and communicating’. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women.DiscussionThe nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice.ConclusionDespite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.     

农村劳动力流动中限制性因素及其消极影响分析

市场经济要求各种生产要素自由流动,但在目前,由于我国多年来固有鄙视农民的观念和害怕农村劳动力流动产生的外部效应,导致政府、企业主对农村劳动力从户籍、工资、福利、工作岗位等多方面进行限制,以达到减少农村劳动力流动.事实上,农村劳动力的流动是必然趋势.限制措施已造成市场经济观念、运行规则在农村发展缓慢,农民的地域思想在加强,易激化城乡矛盾,影响社会的稳定.另外,限制措施严重影响了农村经济发展,导致内需乏力,成为制约我国整体经济健康发展的重要因素.