Exploring outcomes for women and neonates having skin-to-skin contact during caesarean birth: A quasi-experimental design and qualitative study

ProblemWomen having an elective caesarean birth are often separated from their babies at birth with newborns transferred to a postnatal ward with the significant other.BackgroundTwo midwives were employed in 2019 to provide skin-to-skin contact for women who planned for elective caesarean births in a public hospital in metropolitan New South Wales with 4000 births per year and a 39% CB rate (57.8% of these births being elective).AimTo compare the outcomes for women and their newborns on the effects of skin-to-skin contact at elective caesarean births within the first five minutes of birth to those who did not have skin-to-skin contact and to explore the lived experiences of women having skin-to-skin contact during their elective caesarean births.MethodsA quasi-experimental design study with a qualitative component of in-depth interviews. Quantitative analyses included independent t-tests, chi square and logistic regression. Thematic analysis was used for the qualitative data.FindingsIn the quantitative results, there was a reduction in the time to the first feed (t(100) = ?11.32, p < 0.001) (M = 38.9, SE = 20.7) (M = 124.9, SE = 50.1) and the first breastfeed (t(100) = ?5.2, p < 0.001) (M = 53.2, SE = 82.5) (M = 277, SE = 295.8) with increased breastfeeding on discharge for women that had skin-to-skin contact at caesarean birth in comparison to those who did not receive skin-to-skin contact χ2(1) = 10.22, p < 0.05. In the qualitative results, women who had skin-to-skin contact during their caesarean birth had a positive experience with improved bonding and reported less anxiety and depression than their previous caesarean birth.ConclusionThis study provides evidence of the benefits of skin-to-skin contact during a caesarean birth.     

Quantifying the differences in birth outcomes and out-of-pocket costs between Australian Defence Force servicewomen and civilian women: A data linkage study

ObjectivesServicewomen in Defence Forces the world over are constrained in their health service use by defence healthcare policy. These policies govern a woman’s ability to choose who she receives maternity care from and where. The aim of this study was to compare Australian Defence Force (ADF) servicewomen and children’s birth outcomes, health service use, and out-of-pocket costs to those of civilian women and children.MethodsRetrospective cohort study using linked administrative data for women giving birth between 1 July 2012 and 30 June 2018 in Queensland, Australia (n = 365,138 births). Women serving in the ADF at the time of birth were identified as having their care funded by the Department of Defence (n = 395 births). Propensity score matching was used to identify a mixed public/private civilian sample of women to allow for comparison with servicewomen, controlling for baseline characteristics. Sensitivity analysis was also conducted using a sample of civilian women accessing only private maternity care.FindingsNearly all servicewomen gave birth in the private setting (97.22%). They had significantly greater odds of having a caesarean section (OR 1.71, 95%CI 1.29?2.30) and epidural (OR 1.56, 95%CI 1.11?2.20), and significantly lower odds of having a non-instrumental vaginal birth (OR 0.57, 95%CI 0.43?0.75) compared to women in the matched public/private civilian sample. Compared to civilian children, children born to servicewomen had significantly higher out-of-pocket costs at birth ($275.93 ± 355.82), in the first ($214.98 ± 403.45) and second ($127.75 ± 391.13) years of life, and overall up to two years of age ($618.66 ± 779.67) despite similar health service use.ConclusionsADF servicewomen have higher rates of obstetric intervention at birth and also pay significantly higher out-of-pocket costs for their children’s health service utilisation up to 2-years of age. Given the high rates of obstetric intervention, greater exploration of servicewomen’s maternity care experiences and preferences is warranted, as this may necessitate further reform to ADF maternity healthcare policy.     

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour

BackgroundApproximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of ‘normal’ labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context.AimTo examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth.MethodsEthnography, underpinned by a critical medical anthropology methodology.ResultsThese findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence.ConclusionsAs we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a ‘risky’ practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more ‘dangerous’ option.     

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.     

Caesarean section by country of birth in New South Wales,Australia

ObjectiveTo determine rates of caesarean section by country of birth and by obstetric risks.MethodsWe analysed the New South Wales Perinatal Data Collection data of women giving birth between January 2013 and December 2015. Obstetric risk was classified using the Robson’s 10-group classification. Multilevel logistic regression with a random intercept was used to measure the variation in caesarean section rate between immigrants from different countries and between regional immigrant groups.ResultsWe analysed data from 283,256 women, of whom 90,750 had a caesarean section (32.0%). A total of 100,120 women were born overseas (35.3%), and 33,028 (33.0%) had a caesarean section. The caesarean section rate among women from South and Central Asia ranged from 32.6% for women from Pakistan to 47.3% for women from Bangladesh. For South East Asia, women from Cambodia had the lowest caesarean section rate (19.5%) and women from Indonesia had the highest rate (37.3%). The caesarean section rate for North Africa and the Middle East ranged from 28.0% for women from Syria to 50.1% for women from Iran. Robson groups that accounted for most of the caesarean sections were women who had previous caesarean section (36.5%); nulliparous women, induced or caesarean section before labour (26.2%); and nulliparous women, spontaneous labour (8.9%).ConclusionsThe caesarean section rate varied significantly between women from different countries of birth within the same region. Women from some countries of birth had the higher caesarean section rates in some Robson groups.     

Fear of birth: Prevalence,counselling and method of birth at five obstetrical units in Norway

BackgroundThere is increasing evidence that fear of birth can have long-term effects on the childbearing woman and the method of birth.AimTo examine differences between five hospitals in Norway in the occurrence of fear of birth, counselling received and method of birth.MethodSource data was from the Norwegian cohort of the Bidens study and retrieved through a questionnaire and electronic patient records from five different hospitals in Oslo, Drammen, Tromsø, Ålesund and Trondheim, which included 2145 women. The Wijma Delivery Expectancy Questionnaire measured fear of birth, and a cut-off of ≥85 was used to define fear of birth.ResultsIn total, 12% of the women reported fear of birth, with no significant differences between the different units. A total of 8.7% received counselling according to hospital obstetrical records, varying significantly from 5.7% in Drammen to 12.7% in Oslo. Only 24.9% of the women with fear of birth had counselling at their hospital. All the units provided counselling for women with fear, but the content varied. Overarching aims included helping women develop coping strategies like writing a birth plan and clearing up issues regarding prior births. A secondary objective was to prevent unnecessary caesarean section. Both primi- and multiparous women who reported fear of birth had a twofold increased risk of a planned caesarean section.ConclusionThere were no differences between five Norwegian hospitals regarding the occurrence of fear of birth. Counselling methods, resources, level of commitment and the number of women who received counselling varied; thus, hospital practices differed.     

Giving birth after caesarean: Identifying shared preferences among pregnant women using Q methodology

BackgroundCaesarean rates are rising worldwide, the main contributor being the elective repeat caesarean. During the past decades, rates of vaginal birth after caesarean dropped considerably. This requires insight in women’s preferences regarding giving birth following a previous caesarean.AimTo gain a better understanding of women’s values and preferences regarding the upcoming birth following a previous caesarean. Using Q methodology, this study systematically explores and categorises their preferences.MethodsQ methodology is an innovative research approach to explore and compare a variety of viewpoints on a certain subject. Thirty-one statements on birth after caesarean were developed based on the health belief model. Thirty-six purposively sampled pregnant women with a history of caesarean ranked these statements from least to most important. By-person factor analysis was used to identify patterns which, supplemented with interview data, were interpreted as preferences.FindingsThree distinct preferences for giving birth after a caesarean were found; (a) “Minimise the risks for me and my child”, giving priority to professional advice and risk of adverse events, (b) “Seek the benefits of normal birth”, desiring to give birth as normal as possible for both emotional and practical reasons, (c) “Opt for repeat caesarean”, expressing the belief that a planned caesarean brings comfort.ConclusionsPreferences for birth after caesarean vary considerably among pregnant women. The findings help to understand the different types of information valued by women who need to decide on their mode of birth after a first caesarean.     

Using epidemiological and health economic measures to inform maternity staffing decisions: A guide

BackgroundThere is growing concern around unnecessary intervention (particularly caesarean section) at birth in high-income countries. Caseload midwifery care aims to offset this, but is perceived to be costly to health services.AimTo use epidemiological and health economic techniques to estimate health outcomes and cost-savings of different levels of equivalent full time (EFT) midwives working in caseload midwifery care.MethodsTwo simulations were conducted — one assuming 10 EFT midwives working in a caseload model, with 35 women per caseload, and one assuming 50 EFT midwives working in a caseload model, with 45 women per caseload. Both were based on a sample of 5000 women. The main model inputs included rates of health outcomes for women (caesarean section, epidural anaesthesia, and episiotomy) and infants (low birthweight and admissions to special care nursery (SCN) or neonatal intensive care unit (NICU)), and the cost savings associated with health outcome avoidance.FindingsThe first simulation estimated 27 fewer caesarean sections, 12 fewer epidurals, 12 fewer episiotomies, 10 fewer low birthweight births, and 23 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$1,874,715. The second simulation estimated 173 fewer caesarean sections, 76 fewer epidurals, 76 fewer episiotomies, 65 fewer low birthweight births, and 150 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$12,051,741.ConclusionThis study provides local-level decision-makers with a decision-tool to calculate the potentially avoidable health outcomes and cost savings associated with implementing caseload midwifery care in their own service.     

The experience of giving birth with epidural analgesia

Problem and backgroundThere is a lack of literature about what constitutes good midwifery care for women who have epidural analgesia during labour. It is known that an increasing number of women receive epidural analgesia for labour pain. We also know that while women rate the painkilling effect of the epidural analgesia as high, in general, their satisfaction with labour is unchanged or even lower when epidural analgesia is used.QuestionHow do women experience being in labour with epidural analgesia, and what kind of midwifery care do they, consequently, need?MethodsA field study and semi-structured interviews were conducted on a phenomenological basis. Nine nulliparous women were observed from initiation of epidural analgesia until birth of their baby. They were interviewed the day after the birth and again 2 months later. The involved midwives were interviewed 2–3 h after the birth.FindingsInitiation of epidural analgesia can have considerable implications for women's experience of labour. Two different types of emotional reactions towards epidural analgesia are distinguished, one of which is particularly marked by a subtle sense of worry and ambivalence.Another important finding refers to the labouring woman's relationship with the midwife, which represents an essential influencing factor on the woman’ experience of labour. Within this relationship, some rather unnoticed matters of communication and recognition appear to be of decisive significance.ConclusionAfter initiation of epidural analgesia the requirements of midwifery care seem to go beyond how women verbalise and define their own needs. The midwife should be attentive to the labouring woman's type of emotional reaction to epidural analgesia and her possible intricate worries.     

Comparing the course of anxiety in women receiving their first or repeated caesarean section: A prospective cohort study

BackgroundAround 30% of births are through caesarean section and repetition rates for receiving a caesarean section are high.AimThe aim of the prospective study was to compare the course of anxiety in women undergoing their first caesarean section and women experiencing a repeated caesarean section.Participants304 women with an indication for an elective caesarean section took part. 155 received their first caesarean section and 149 received a repeated caesarean section.MethodsIn order to measure the course of anxiety on the day of the caesarean section subjective anxiety levels were measured and saliva samples for cortisol determination were taken at admission, during skin closure and two hours after the surgery. Blood pressure and heart rate were documented at skin incision and skin closure.ResultsWomen experiencing their first caesarean section displayed significantly higher anxiety levels compared to women with a repeated caesarean section. Scores of the STAI-State and visual analogue scale for anxiety differed significantly at admission (p = .006 and p < .001) and heart rate and alpha amylase levels were significantly higher at skin closure (p = .027 and p = .029).ConclusionThe results show that previous experience with a caesarean section has a soothing effect. The study aims to sensitize surgeons, anesthetists, nurses and midwives when treating women receiving a caesarean section and encourage them to incorporate soothing interventions, especially for women receiving their first caesarean section to reduce anxiety levels and consequently improve postoperative recovery and patients’ satisfaction.     

Perinatal factors related to post-traumatic stress disorder symptoms 1–5 years following birth

BackgroundThe relationship between perinatal variables and post-traumatic stress disorder (PTSD) symptoms was studied. However, the role of some variables in PTSD symptoms is unclear.AimDetermine the prevalence of PTSD symptoms after 1 year postpartum and their relationship with perinatal variables.MethodsA cross-sectional study with 1531 puerperal women in Spain. Data were collected on socio-demographic variables, perinatal variables (maternal characteristics, procedures during labour and birth, birth outcomes and time since birth) and the newborn. An online questionnaire was used, which included the Perinatal Post-traumatic Stress Questionnaire (PPQ). Crude and adjusted odds ratios (OR) were calculated using binary logistic regression.Findings7.2% (110) of the women were identified as being at risk for probable PTSD symptoms. Protective factors were having a birth plan respected (aOR 0.44; 95%CI 0.19−0.99), use of epidural analgesia (aOR 0.44; 95%CI 0.24−0.80) and experiencing skin-to-skin contact (aOR 0.33; 95%CI 0.20−0.55). Risk factors were instrumental birth (aOR 3.32; 95%CI1.73−3.39), caesarean section (aOR 4.80; 95%CI 2.51–9.15), receiving fundal pressure (aOR 1.72; 95%CI 1.08–2.74) and suffering a third/fourth degree perineal tear (aOR 2.73; 95%CI 1.27–5.86). The area under the model’s ROC curve was 0.82 (95%CI 0.79−0.83).ConclusionsWomen who experience a normal birth, are psychologically prepared for birth (for example, through use of a birth plan), experience skin-to-skin contact with their newborn, and had a sense of physical control through the use of epidural analgesia, are less likely to experience childbirth as traumatic.     

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.     

Qualitative assessment of women's experiences with ECV

For women with unsuccessful ECV, discussions about their mode of delivery should include the benefits and risks of a planned caesarean or vaginal breech birth. However, most obstetric units continue to offer only planned caesarean births when ECVs are unsuccessful despite the proven safety of vaginal breech births in selected patients. Such unit policies can be at variance with a woman's desire and preference for vaginal birth. Thus, a conflict situation arises that could have varying medical, emotional and cultural implications.AimTo provide a consumer perspective on ECV from women who had an unsuccessful procedure.MethodologyA qualitative study involving focus group discussions with women who had unsuccessful ECV at secondary obstetric facility in Melbourne, Australia.ResultsEmergent themes from the focus group discussions were related to emotions associated with the inevitability of a caesarean section for breech, consequences of an unsuccessful ECV and the various activities undertaken by women to induce spontaneous version.ConclusionA medicalized approach to ECV fell short of women's expectations of care. There is a need to develop strategies that will help women deal with any conflicts occasioned by an unsuccessful ECV.     

How obstetricians and pregnant women decide mode of birth in light of a recent regulation in Brazil

Background

In Brazil, 88% of births among women with private insurance are caesarean sections, even though a caesarean rate above 15% is associated with greater maternal and child morbidity and mortality. Aiming to reduce unnecessary caesarean sections in the private sector, in July 2015 the Brazilian government enacted Resolução Normativa 368, a regulation requiring the use of partograms, pre-natal cards to document pregnancies, and consent forms for elective caesareans, and recommending that obstetricians provide women with an informational letter about birth.

Timing of hospital admission in labour: latent versus active phase,mode of birth and intrapartum interventions. A correlational study

Background

Hospitalization of women in latent labour often leads to a cascade of unnecessary intrapartum interventions, to avoid potential disadvantages the recommendation should be to stay at home to improve women’s experience and perinatal outcomes.

Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital

BackgroundThere is national and international concern for increasing obstetric intervention in childbirth and rising caesarean section rates. Repeat caesarean section is a major contributing factor, making primiparous women an important target for strategies to reduce unnecessary intervention and surgeries in childbirth.AimThe aim was to compare outcomes for a cohort of low risk primiparous women who accessed a midwifery continuity model of care with those who received standard public care in the same tertiary hospital.MethodsA retrospective comparative cohort study design was implemented drawing on data from two databases held by a tertiary hospital for the period 1 January 2010 to 31 December 2011. Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05.ResultsData for 426 women experiencing continuity of midwifery care and 1220 experiencing standard public care were compared. The study found increased rates of normal vaginal birth (57.7% vs. 48.9% p = 0.002) and spontaneous vaginal birth (38% vs. 22.4% p = <0.001) and decreased rates of instrumental birth (23.5% vs. 28.5% p = 0.050) and caesarean sections (18.8% vs. 22.5% p = 0.115) in the midwifery continuity cohort. There were also fewer interventions in this group. No differences were found in neonatal outcomes.ConclusionStrategies for reducing caesarean section rates and interventions in childbirth should focus on primiparous women as a priority. This study demonstrates the effectiveness of continuity midwifery models, suggesting that this is an important strategy for improving outcomes in this population.