Determinants of prenatal health care utilisation by low-risk women: A prospective cohort study

BackgroundPrenatal health care is pivotal in providing adequate prevention and care to pregnant women.AimWe examined the determinants of inadequate prenatal health care utilisation by low-risk women in primary midwifery-led care in the Netherlands.MethodsWe used longitudinal data from the population-based DELIVER study with 20 midwifery practices across the Netherlands in 2009 and 2010 as the experimental setting. The participants were 3070 pregnant women starting pregnancy care in primary midwifery care.FindingsWe collected patient-reported data on potential determinants of prenatal care utilisation derived from the Andersen model. Prenatal health care utilisation was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and number of visits. Low-risk pregnant women (not referred during pregnancy) were more likely to use prenatal care inadequately if they intended to deliver at a hospital, if they did not use folic acid adequately periconceptionally, or if they were exposed to cigarette smoke during pregnancy. Among those who were referred to secondary care, women reporting a chronic illnesses or disabilities, and women who did not use folic acid periconceptionally were more likely to make inadequate use of prenatal care.ConclusionInadequate prenatal health care use in primary midwifery care is more likely in specific groups, and the risk groups differ when women are referred to secondary care. The findings suggest routes that can target interventions to women who are at risk of not adequately using prenatal prevention and care services.     

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.     

The effects of preconception desires and intentions on pregnancy wantedness

Do preconception intentions to conceive add to the prediction of pregnancy wantedness beyond the effect of preconception desires? This paper addresses that question, using data regarding the most recent pregnancy of 2,299 women respondents to the 2002 U.S. National Survey of Family Growth. We test a structural equation model predicting a woman’s pregnancy wantedness with her preconception desires, her perception of her partner’s preconception desires, and her preconception intentions. In this multivariate setting, preconception intentions do not predict pregnancy wantedness in the overall sample. However, they do predict wantedness in certain demographic contexts. We identify three patterns of change in our model that occur in selected contexts. We then use these patterns to hypothesize three psychosocial mechanisms by which preconception intentions may increase the wantedness of a pregnancy beyond that resulting from the woman’s preconception desires to get pregnant and her perception of her partner’s preconception desires.     

Negotiating who gives birth and the influence of fear of childbirth: Lesbians,bisexual women and transgender people in parenting relationships

BackgroundFear of childbirth (FOC) may affect family planning in lesbian, bisexual and transgender (LBT) couples with two potential carriers of a pregnancy. FOC has previously been researched in heterosexual women, while experiences of LBT people have remained unattended. The choice of birth-giving partner in same-sex couples has gained some attention in previous research, but the potential complexities of the decision have not been studied.AimThe aim is to explore how LBT people negotiate the question of who gives birth, in couples with two potential birth parents, and where one or both partners have a pronounced FOC.MethodsSeventeen self-identified LBT people were interviewed about their expectancies and experiences of pregnancy and childbirth. Data were analysed following a six-step thematic analysis.ResultsFOC was negotiated as one of many aspects that contributed to the decision of who would be the birth-giving partner. Several participants decided to become pregnant despite their fears, due to a desire to be the genetic parent. Others negotiated with their partner about who was least vulnerable, which led some of them to become pregnant despite FOC. Still other participants decided to refrain from pregnancy, due to FOC, and were delighted that their partner would give birth. Several participants described their partner's birth-giving as a traumatic experience for them, sometimes also when the birth did not require any obstetric interventions. The partner's experience was in some cases not addressed in postnatal care.ConclusionsIt is important that healthcare staff address both partners’ prenatal expectancies and postnatal experiences.     

A selective review of prenatal exercise guidelines since the 1950s until present: Written for women,health care professionals,and female athletes

BackgroundTraditional society values have long-held the notion that the pregnant woman is construed as a risk to her growing fetus and is solely responsible for controlling this risk to ensure a healthy pregnancy. It is hard to ignore the participation of pregnant women in sport and exercise today, especially in high-level sports and popular fitness programs such as CrossFit™. This challenges both traditional and modern prenatal exercise guidelines from health care professionals and governing health agencies. The guidelines and perceived limitations of prenatal exercise have drastically evolved since the 1950s.AimThe goal of this paper is to bring awareness to the idea that much of the information regarding exercise safety during pregnancy is hypersensitive and dated, and the earlier guidelines had no scientific rigor. Research is needed on the upper limits of exercise intensity and exercise frequency, as well as their potential risks (if any) on the woman or fetus.DiscussionPregnant women are physically capable of much more than what was once thought. There is still disagreement about the types of exercise deemed appropriate, the stage at which exercise should begin and cease, the frequency of exercise sessions, as well as the optimal level of intensity during prenatal exercise.ConclusionResearch is needed to determine the upper limits of exercise frequency and intensity for pregnant women who are already trained. Healthy women and female athletes can usually maintain their regular training regime once they become pregnant.     

Comment on 'facts and artifacts in the study of intra-uterine mortality: a reconsideration from pregnancy histories' by henri léridon(1)

Abstract Extract I have suggested that at a given birth order the probability of having a further pregnancy is greater when the last pregnancy had been spontaneously aborted than when it resulted in a birth.(2) Léridon,(3)in the course of a valuable paper on foetal wastage, presents data which, according to him, impugn my suggestion. I would like to question his claim.     

Trends in Self-reported Spontaneous Abortions: 1970–2000

Little is known about how the miscarriage rate has changed over the past few decades in the United States. Data from Cycles IV to VI of the National Survey of Family Growth (NSFG) were used to examine trends from 1970 to 2000. After accounting for abortion availability and the characteristics of pregnant women, the rate of reported miscarriages increased by about 1.0% per year. This upward trend is strongest in the first seven weeks and absent after 12?weeks of pregnancy. African American and Hispanic women report lower rates of early miscarriage than do whites. The probability of reporting a miscarriage rises by about 5% per year of completed schooling. The upward trend, especially in early miscarriages, suggests awareness of pregnancy rather than prenatal care to be a key factor in explaining the evolution of self-reported miscarriages. Any beneficial effects of prenatal care on early miscarriage are obscured by this factor. Differences in adoption of early-awareness technology, such as home pregnancy tests, should be taken into account when analyzing results from self-reports or clinical trials relying on awareness of pregnancy in its early weeks.     

Comment on ‘Facts and Artifacts in the Study of Intra-Uterine Mortality: A Reconsideration from Pregnancy Histories’ by Henri Léridon1

Extract

I have suggested that at a given birth order the probability of having a further pregnancy is greater when the last pregnancy had been spontaneously aborted than when it resulted in a birth.² Léridon,³in the course of a valuable paper on foetal wastage, presents data which, according to him, impugn my suggestion. I would like to question his claim.     

Applying information to improve family planning in Gaoping County]

The scientific management method of improving family planning through information has produced a low birth rate and natural increase rate in Gaoping County, China, since 1976. In order to promote good family planning, Gaoping County incorporated the scientific management method with the establishment of an information network that included information banks, files, and newspaper columns. The officials of Gaoping County focused their efforts on women most susceptible to unplanned childbirth, e.g., women uneducated in birth control and prenatal care. The women were divided into groups according to their educational needs, e.g., women who were hesitant toward birth control, women who used birth control, women who never reproduced, and women who were newly married. By educating these women to the aspects of planned childbirth, prenatal testing, prenatal care, and contraceptives, Gaoping County effectively promoted good family planning in the areas of birth control and family health. The following statistics are the results of incorporating the scientific management system in family planning of Gaoping County. In 1983, the birth rate in Gaoping County was 11.3%, a 2.8% decline from 1982; the mortality rate decreased 0.2% to a rate of 7.6%; and the natural increase rate decreased 2.6% to a rate of 3.7%. The planned birth rate in 1983 was 90.1% and the rate of 1 child per couple was 91%. This was an increase from the 1982 rates of 21.3% and 25.2%, respectively. From January 1984 to June 1984 the planned birth rate reached 97.2%. These statistics are evidence of the positive results in using information in family planning.     

Unwanted pregnancies and preventive health care use in Thailand

Research on the consequences of unwanted pregnancies can offer useful perspectives on the need to improve and expand the range of family planning options available to women in developing countries. This paper investigates the use of maternal and child health services by women who have unwanted or mistimed pregnancies. The results of our analysis indicate that wantedness of births exerts a significant influence on health care use in Thailand, after controlling for other determinants of utilization. Women with unwanted pregnancies are less likely to seek prenatal care or receive tetanus toxide inoculations. Further, women from disadvantaged socioeconomic groups, women with high parity and those with lower educational levels have the highest proportion of unintended pregnancies. The study concludes by making suitable policy recommendations.     

Are pregnant women with asthma receiving guideline-recommended antenatal asthma management? A survey of pregnant women receiving usual care in Australia

BackgroundAsthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4–6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia.AimTo explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations.MethodPregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019.ResultsThe survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving ‘usual’ care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information.ConclusionsOverall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.     

A glance into the hidden burden of maternal morbidity and patterns of management in a Palestinian governmental referral hospital

BackgroundLittle is known about the burden and patterns of maternal morbidity during childbirth, particularly in the Middle East Region. Investigating the patterns of maternal morbidity can be useful in guiding improvement in the quality of maternal services, and informing policy debates on women's health.ObjectiveTo examine the incidence, types and patterns of management of severe and non-severe maternal morbidities of Palestinian women during pregnancy, labour, delivery and up to seven days postpartum in one Palestinian hospital.MethodsA prospective hospital-based study was conducted for a 3-month period in 2011–2012, reviewing hospital records for all pregnant women (1.583) admitted to the governmental hospital in Ramallah, Palestine.FindingsOf all pregnant women included in this analysis (1.558), 419 (26.9%) women experienced one or more maternal morbidities and 15 (0.96%) women survived a life-threatening complication (near miss). Of all women who suffered morbidities, 69 (16.5%) had vaginal deliveries, 61 (14.6%) had cesarean sections, 179 (42.7%) had abortions/miscarriage, and 110 (26.3%) experienced complications during pregnancy or the post-partum. Hemorrhage during pregnancy, birth or postpartum was the most common morbidity. Of those who gave birth, women who gave birth by cesarean sections were three times more likely to suffer from morbidities than those who had vaginal delivery.ConclusionsThe burden of maternal morbidity for Palestinian women between the ages of 16 and 48 is high. In Palestine, maternal morbidity can be prevented by promoting a rational use of cesarean section, avoiding unnecessary medicalization, reducing unwanted pregnancies and updating practices of providers related to abortion/miscarriage care.     

Pattern of prenatal care utilization in Tehran: A population based longitudinal study

Aim

To assess the pattern of prenatal care utilization in Tehran in 2015.

Psychological distress in pregnancy and postpartum

PurposeDepression, stress, and anxiety, termed ‘psychological distress,’ are common in pregnancy and postpartum periods. However, it is unclear whether prenatal psychological distress predicts postpartum psychological distress. We studied the prevalence, comorbidity and associations of maternal depression, stress, and anxiety in the prenatal period in relation to the occurrence of these same measures in the postpartum period.MethodsData originated from the MotherToBaby study of pregnant women residing in the U.S or Canada (2016–2018). Risk ratios and 95% Confidence Intervals using modified-Poisson regression models were used to investigate associations between prenatal psychological distress and postpartum psychological distress.ResultsOf the 288 women in the analysis, 21.2% and 26.7% of women had evidence of prenatal and postnatal psychological distress, respectively. Among those with prenatal psychological distress, 43 (70.5%) also had postpartum psychological distress. Twenty-five (41%) of those with prenatal and 46 (60%) of those with postpartum psychological distress had comorbidity of at least two of the measures. Prenatal measures independently predicted the same postnatal measures; prenatal anxiety also independently predicted postpartum stress. Participants who experienced more types of prenatal psychological distress were at higher risk for postpartum depression, stress, and anxiety.ConclusionDepression, stress, and anxiety are common in pregnant women and often occur together. Prenatal psychological distress measures are associated with postnatal psychological distress measures, with stronger associations among women with more than one type of psychological distress in pregnancy. Interventions during pregnancy may reduce the risk of postpartum psychological distress.     

Shanghai adopts family planning regulations

These Regulations, adopted by the Municipal People's Congress of Shanghai on 14 March 1990, do the following: a) strictly prohibit any units and individuals from identifying the sex of a fetus without medical reasons; b) add 1 additional week to the marriage leave of couples who marry at the age set for late marriage (25 for males and 23 for females); c) add 15 days of maternity leave for women who give birth at the age set for late birth (24) and 3 days for their spouses; d) impose a fine equal to 3 to 6 times their average annual income if a couple have an unplanned birth (calculated on the basis of their income 2 years before the birth); and e) subject a couple who have an unplanned birth to disciplinary action by their working units if they work for others or by the administrative department of industry and commerce if they are self employed. Second births are allowed if a first child "can not become normal because of nonhereditary diseases," if both husband and wife are single children, or if a "remarried couple had only one child before their remarriage." The Regulations provide that "the improvement of birth quality and good upbringing of children should be promoted, advice on heredity should be provided, and premarital examinations [should] be conducted." They also stipulate that "A woman should terminate her pregnancy or undergo a sterilization operation if both husband and wife (or either of them) have [a] hereditary or other disease not medically suitable for birth." The provisions of these Regulations prohibiting prenatal sex selection were reported in Annual Review of Population Law, Vol. 17, 1990, Section 240.     

Conceptual and ethical problems underpinning calls to abandon vaginal breech birth

The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to “abandon vaginal breech birth” mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.     

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.