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.     

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

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

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

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

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

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

Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women’s experiences and birth outcomes

IntroductionThe ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women’s experiences and birth outcomes.AimTo evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care.MethodAn anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included.FindingsThe response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6–8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes.ConclusionThis innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators.     

Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study

ProblemWomen increasingly present to hospital in early labour, but admission before active labour contributes to overuse of interventions, poorer clinical and psychological outcomes, and higher healthcare costs.BackgroundInnovative models of early labour care have so far not improved birth outcomes.AimTo examine if reconfiguring the early labour service in a large Australian maternity service improved (1) the birth outcomes of women who presented in early labour and (2) alleviated bed blockages by decreasing length of stay in the Pregnancy Assessment and Observation Unit.MethodsPre-post intervention design, using routinely collected clinical data before and after the implementation of the reconfigured early labour service.FindingsThere were 527 women in pre-intervention cohort and 747 in the post-intervention cohort. The two groups were similar in age, body mass index, marital status, education level and gestation at birth. Post intervention, epidural use did not change significantly, but rates of amniotomy (35.7% vs. 49.9%, p = <0.001), meconium-stained liquor (20.1% vs 26.1%, p = 0.04), and neonatal nursery admission (2.7% vs. 5.8% p = 0.01) increased. The proportion of women staying in the Assessment unit more than two hours decreased, but not significantly.ConclusionChanging the location and model of early labour care did not influence epidural use, nor improve women’s birth outcomes. For women in early labour, admission to any location within the hospital may be as problematic as admission to birth suite specifically.     

An ethnographic study of the interaction between philosophy of childbirth and place of birth

BackgroundOrganisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings.AimTo explore how childbirth is constructed and influenced by context in three birth settings in Australia.MethodThis ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6–8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16).ResultsAll home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through ‘running the gauntlet’, based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident.ConclusionsA complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.     

Women's expectations and experiences with labour pain in medical and midwifery models of birth in the United States

BackgroundThis research focuses on how women understand and experience labour as related to two competing views of childbirth pain. The biomedical view is that labour pain is abnormal and anaesthesia/analgesia use is encouraged to relieve the pain. The midwifery view is that pain is a normal part of labour that should be worked with instead of against.AimsTo determine differences in the preparation for and experiences with labour pain by women choosing midwives versus obstetricians.MethodsPrenatal and postpartum in-depth semi-structured interviews were conducted with a convenience sample of 80 women in Florida (United States): 40 who had chosen an obstetrician and 40 who had chosen a licensed midwife as their birth practitioner.FindingsWomen in both groups were concerned with the pain of childbirth before and after their labour experiences. Women choosing midwives discussed preparing for pain through various non-pharmaceutical coping methods, while women choosing physicians discussed pharmaceutical and non-pharmaceutical pain relief.ConclusionsEqual numbers of women expressed concerns with childbirth pain during the prenatal interviews, while more women choosing doctors spoke about pain after their births. Women had negative experiences when their planned pain relief method, either natural or medical, did not occur. The quandary facing women when it comes to labour pain relief is not choosing what they desire, but rather preparing themselves for the possibility that they may have to accept alternatives to their original preferences.     

Does the way maternity care is provided affect maternal and neonatal outcomes for young women? A review of the research literature

BackgroundYoung pregnant women who continue a pregnancy are primarily from a socioeconomically deprived background. The risk factors associated with low socio-economic status may independently affect perinatal and neonatal morbidity to a greater extent than the young age of the woman. Young pregnant women are frequently sceptical about health care providers who they can perceive to be judgemental. This may lead to late booking for pregnancy care, attending few appointments, or not attending the health service for any antenatal care.QuestionDoes the way maternity care is provided affect maternal and neonatal outcomes for young women?MethodA systematic search of the major health databases.ResultsNine research articles met the eligibility criteria: one randomised controlled trial, three prospective cohort studies, two comparative studies with concurrent controls, two comparative studies with historical controls, and one case series.DiscussionProviding young women with a non-standard model of maternity care has some beneficial and no known detrimental effects on childbirth outcomes. While there is a dearth of evidence on the effectiveness of a Midwifery Group Practice model of care for young women, there is strong evidence to suggest that a Group Antenatal Care model increases antenatal visit attendance and breastfeeding initiation, and decreases the risk of preterm birth. There is research to indicate that a Young Women's Clinic model may also increase antenatal visit attendance and decrease the incidence of preterm birth.ConclusionMore well-designed and resourced midwifery models of care for young women should be implemented and rigorously researched.     

Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women

Background and purposePerinatal mental health problems have been studied in more than 90% of high income countries but this information is available only for 10% of low and middle income countries. A study on the relationship between anxiety during pregnancy and postpartum depression has not been performed in Iran. This prospective study aimed to investigate whether anxiety and fear of childbirth during pregnancy is an independent predictor of postpartum depressive symptoms.MethodsIn this prospective longitudinal study participants were 160 women with a gestational age of 28–30 weeks from 10 prenatal care clinics in Qom, Iran. Subjects were interviewed and the State-Trait Anxiety Inventory (STAI) and Childbirth Attitudes Questionnaire (CAQ) were completed at 28 and 38 weeks of gestation. They were followed up 45 days and 3 months after childbirth. Postpartum depression was defined as a score ≥ 13 on the Edinburgh Postpartum Depression Scale (EPDS).ResultsAntenatal state anxiety (odds ratio [OR] = 3.2; P = 0.002 and OR = 2.91; P = 0.007 at 28 and 38 weeks of gestation, respectively) and trait anxiety (OR = 3.33; P = 0.001 and OR = 3.30; P = 0.003 at 28 and 38 weeks of gestation, respectively) increased the risk of postpartum depression 45 days after birth (P < 0.05). Likewise, the presence of antenatal state and trait anxiety at 28 and 38 weeks of gestation significantly increased the risk of postpartum depression during the first three months after childbirth (P < 0.05). On the contrary, prenatal fear of childbirth was not a significant predictor of postpartum depression symptoms (P > 0.05).ConclusionsThe findings from this study suggest that antenatal state and trait anxiety, assessed by interview, is an important predictor of postpartum depression. Therefore, it should be routinely screened in order to develop specific preventive interventions.     

Perceptions of paternal involvement and labour pain management in Chinese couples during childbirth: A qualitative study

BackgroundLabour pain is an individual experience embedded in a socio-cultural context. In childbirth, the father’s involvement provides important support to the mother during labour. However, few published studies have evaluated couples’ experiences of paternal involvement and labour pain management in the Chinese context.AimThis study aimed to understand the experience of labour pain management and the father’s involvement in childbirth from the perspectives of women and their partners in Hong Kong.MethodsAn exploratory qualitative design was adopted. A purposive sample of 45 Chinese parents was recruited at the postnatal unit of a regional hospital. Data were collected through semi-structured face-to-face interviews within 1 month after birth. The data were subjected to content analysis.FindingsThe findings revealed six major themes: the mothers’ experience of labour pain, effectiveness of pain relief measures, mothers’ perceptions of support from their partners, mothers’ perceptions of support from healthcare professionals, fathers’ experience of involvement in childbirth and suggested improvements to maternity services.DiscussionChinese mothers experienced intense labour pain and used various pain relief measures. Both parents considered the involvement of fathers and support from healthcare professionals to be highly significant during childbirth.ConclusionsThis study highlights the need for a family-centred model of care during childbirth that involves both parents in the decision-making process. Chinese maternity services should implement individualised birth plans that acknowledge both parents’ expectations and preferences, thus promoting a positive childbirth experience for the parents.     

Women's satisfaction with antenatal care: Comparing women in Sweden and Australia

BackgroundSatisfaction with antenatal care could differ depending on the organisation and the context of care.AimTo compare antenatal care in Australia and Sweden, to identify deficiencies in the content of antenatal care and what aspects contributed most in dissatisfaction with antenatal care.MethodsA longitudinal survey of 123 Australian and 386 Swedish women recruited during one year in regional hospitals in Sweden and Australia. Data collected by three questionnaires.ResultsWomen in Australia had more antenatal visits, less continuity of midwife caregiver but were more satisfied with antenatal education and the emotional aspects of antenatal care. Although the overall satisfaction was high, deficiencies were found in more than half of the studied variables in the content of care. Women in Sweden were more dissatisfied with information about labour and birth (OR 3.1; 1.8–5.3) and information about the time following birth (OR 3.8; 2.2–6.3), but more satisfied with the involvement of the father (OR 0.3; 0.2–0.6). Factors that contributed most to dissatisfaction with antenatal care overall were deficiency in information about pregnancy related issues (OR 3.4; 1.3–8.7) and not being taken seriously by the midwife (OR 4.1; 1.6–10.1).ConclusionSatisfaction with antenatal care was high in both groups of women. Australian women were more satisfied than the Swedish women with the emotional aspects of care. Deficiencies were found in more than half of the variables measured relating to the specific aspects of care. Lack of information and not being treated seriously were important factors for not being satisfied.     

Factors affecting rural women's utilisation of continuum of care services in remote or isolated villages or Pakistan – A mixed-methods study

IntroductionAn effective continuum of care for pregnancy and childbirth connects women and girls with essential reproductive and maternity care services. This study aimed to estimate the continuum of care utilisation rate of women who lived in remote and isolated regions of Pakistan and explored factors that influence women's utilisation of reproductive and maternity care services.MethodsA mixed-methods study was conducted in five rural villages of Sindh, Pakistan. A cross-sectional survey with 669 women who gave birth between July 2010 and September 2014 investigated women's maternity-care service utilisation during pregnancy, childbirth, and in the postpartum period. In-depth interviews with 15 women explored their maternity-care experiences with health providers.ResultsOnly 6.4% of 669 women participants reported to have completed the continuum of care for their last pregnancy. Skilled birth attendants, including health professionals, were used by 56.1% for antenatal care, 40.8% for both antenatal and childbirth, 22.3% for antenatal, childbirth and postnatal, and only 6.4% reported using all pregnancy-related and postpartum services. Limited knowledge about affordable health services, poor health literacy, and access to health services was associated with women's fragmented utilisation of maternity care. A lack of respectful maternity-care was also identified as a major barrier to women's utilisation of primary health care facilities, especially for childbirth.ConclusionThe existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services; however, health services utilisation for reproductive and maternity care remains suboptimal in women who live in geographically remote regions of Pakistan.     

‘The calm before the storm’: A qualitative study of fathers’ experiences of early labour

BackgroundEarly labour care presents a challenge for maternity services and is a cause of dissatisfaction for women planning birth in an obstetric or midwifery unit who may feel unsupported or unwelcome at their planned place of birth. Little is known about the perspectives of men who support their partner during early labour.MethodsOpportunity sample offathers (n = 12) in the UK who had been present during their partner’s labour in the previous twelve months. Semi-structured interviews were audio-recorded and transcribed before thematic analysis.ResultsFathers learned about the stages of labour during antenatal education and felt well prepared for early labour but found their knowledge difficult to apply, and relied on their partners to decide when to travel to the planned place of birth. Early labour was described as the ‘calm before the storm’ during which they carried out practical tasks or rested to ensure they could fulfil their role when labour progressed. However, men frequently felt ‘like a spare part’ during the later stages of labour.DiscussionThe study has implications for antenatal educators, midwives and others supporting couples during pregnancy and labour. It supports reconsideration of how information about labour progress can be most usefully conveyed to couples. Professionals could acknowledge the value of supportive tasks carried out by fathers that might otherwise be experienced as doing ‘nothing’. Further research should recruit more diverse samples of men and same-sex couples. Dyadic data collection methods may be of value.     

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

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

Conflicting contexts: Midwives’ interpretation of childbirth through photo elicitation

IntroductionThis study seeks to explore midwives’ perceptions about childbirth and in particular their beliefs about normality and risk. In the current climate of increasing interventions during labour, it is important to understand the thought processes that impact on midwifery care in order to examine whether these beliefs influence midwifery clinical decision-making.Method12 Midwives who worked in a variety of metropolitan hospitals in Sydney, Australia were interviewed about how they care for women during labour. The study utilised an inductive qualitative design using photo elicitation during the interview process.ResultsSix themes emerged from the data that clearly indicated midwives felt challenged by working in a system dominated by an obstetric model of care that undermined midwifery autonomy in maintaining normal birth. These themes were: desiring normal, scanning the environment, constructing the context, navigating the way, relinquishing desire and reflecting on reality. Most midwives felt they were unable to practice in the manner they were philosophically aligned to, that is, promoting normal birth, as the medical model restricted their practice.DiscussionThe polarised views of childbirth held by midwives and obstetricians do little to enhance normal birth outcomes. Midwives in this study expressed frustration that they were unable to practice midwifery in a way that reflected their belief in normal birth. This, they cite is a result of the oppressive obstetric model prevalent in maternity care facilities in Sydney and the over use of technological interventions during childbirth.     

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.