The EPDS and Australian Indigenous women: A systematic review of the literature

ProblemThe Edinburgh Postnatal Depression Scale (EPDS) is considered the gold standard in perinatal mental health screening and the Australian Clinical Practice Guidelines recommend universal use. However, screening rates are four times lower with Indigenous Australian women compared to non-Indigenous women. Difficulties have been reported using the EPDS in this context.BackgroundEvidence demonstrates the link between perinatal mental health and maternal and child outcomes. Indigenous Australian maternal and child health and wellbeing outcomes remain unacceptably poor across all measured parameters and reported psychological distress and child removal rates are increasing.MethodsA systematic literature review was conducted to assess the effectiveness, validity, reliability, and cultural safety of the EPDS in the Indigenous Australian context and identify the availability and suitability of any adaptations.FindingsThe EPDS has not been validated for use with Indigenous Australian women.DiscussionThe findings and limitations identified in this review are consistent with concerns in other countries about the cross-cultural use of the EPDS and its sensitivity in predicting risk for postnatal depression amongst Indigenous women. Where adaptations of the EPDS have been used there has been no psychometric and cultural validation beyond the remote communities in which they were developed.ConclusionsThere is no evidence to demonstrate that the EPDS in its current form and application is suitable for screening with Indigenous Australian women. Urgent work is required to evaluate and/or develop culturally meaningful screening tools that are predictive of risk for social and emotional wellbeing and perinatal mental distress in this context.     

Talking testing: Impact of a training intervention on midwives’ antenatal HIV,hepatitis B and hepatitis C screening practice

BackgroundMidwives play a critical role in ensuring that HIV, hepatitis B and hepatitis C screening occurs during early pregnancy, in accordance with national consensus guidelines and policies. Limited opportunities exist for midwives to gain the knowledge, skills and confidence required to initiate testing discussions at the first antenatal visit.AimTo design, deliver and evaluate a workforce education intervention to build midwives’ capacity to initiate testing for HIV and viral hepatitis.MethodVictorian midwives were invited to enrol in an intervention which comprised a pre-learning package and a one-day study day covering clinical, epidemiological and psychosocial aspects of HIV, hepatitis B and hepatitis C testing in early pregnancy. A pre-/post-test design, incorporating a survey with eight knowledge items and four confidence items, was used to measure impact.FindingsOf the 69 participating midwives, 55 completed the pre-survey, 69 completed the post-survey and 19 completed a three-month follow up survey. Participant knowledge improved across all domains, with the most significant increases in the areas of HIV and viral hepatitis testing, transmission and treatment. Midwives’ confidence levels increased following the intervention, and this was generally sustained among the smaller sample at the three-months.ConclusionOur findings demonstrate that short educational interventions, designed and delivered by content experts, result in longer-term improvements in clinical practice which are crucial to ensuring women and their partners are given adequate information and recommendations about screening for HIV, hepatitis B and hepatitis C and during pregnancy.     

Refusal of recommended maternity care: Time to make a pact with women?

Background

The right to refuse medical treatment can be contentious in maternity care. Professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy, but there is little guidance available to clinicians about the appropriate clinical responses when women decline recommended care.

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.     

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.     

Being in the shadow of the unknown — Swedish women’s lived experiences of pregnancy during the COVID-19 pandemic,a phenomenological study

BackgroundThe COVID-19 pandemic has had a profound effect on the emotional well-being of expecting mothers. Sweden’s unique strategy for managing COVID-19 involved no national lockdown. Emphasis was instead placed on limiting crowding and asking citizens to practice social distancing measures.AimTo gain a deeper understanding of how women not infected by SARS-CoV-2 experienced pregnancy during the COVID-19 pandemic in Sweden.MethodsThis was a qualitative study with a reflective lifeworld approach. Fourteen women that had not contracted COVID-19 and who were pregnant during the first and second wave of the pandemic were interviewed. Data were analysed with a phenomenological reflective lifeworld approach.FindingsThe essence of the women’s experiences of being pregnant during the COVID-19 pandemic was best described as being in the shadow of the unknown, where the COVID-19 pandemic could at times totally overshadow the experience of being pregnant, while at other times, rays of sunlight pierced through the clouds. The experience was characterised by having to deal with the uncertainties caused by the pandemic and feelings of being in an information echo. Women felt socially isolated and had to face maternal check-ups without the support of their partners. There was, however, a strong trust in maternal health-care services despite the lack of information available.ConclusionBeing in the shadow of the unknown represents the uncertainties posed by the COVID-19 pandemic on the experience of pregnancy. Sufficient information, a companion of choice and screening for emotional well-being are important factors in maternity care during pandemics.     

Knowledge and Attitudes About HIV/AIDS Among Community-Living Older Women: Reexamining Issues of Age and Gender

ABSTRACT

Although older women face unique risks related to HIV/AIDS, little empirical data is available regarding HIV/AIDS among women over the age of 65. In the present study, 160 community-living older women and men completed questionnaires regarding knowledge and attitudes about HIV/AIDS. Findings showed that although older women were less likely to talk to their physician about HIV than men, they maintained greater knowledge and generally dispelled myths about viral transmission. However, most older women believed that HIV/AIDS had limited personal relevance, possessed virtually no knowledge of age and gender specific risk factors, and professed HIV-associated stigma. These findings highlight the need for gender and age specific prevention programs.     

The return of weighing in pregnancy: A discussion of evidence and practice

BackgroundInadequate or excessive gestational weight gain is associated with both short and long-term adverse maternal and infant health outcomes. The practice of routine maternal weight monitoring has been suggested as an effective health promotion intervention, both as a screening tool for adverse maternal and infant outcomes and as a weight management strategy for addressing gestational weight gain.DiscussionThe effectiveness of routine maternal weighing as part of maternity care has been debated for more than 30 years. The National Health and Medical Research Council of Australia have recently revised their pregnancy care clinical practice guidelines recommending maternal weight monitoring (clinician and/or self-weighing) be reintroduced into clinical practice. This paper presents a timely discussion of the topic that will contribute new insights to the debate.ConclusionWeight gain in pregnancy is complex. Evaluation of the translation, implementation, acceptability and uptake of the newly revised guidelines is warranted, given that evidence on the practice remains inconclusive. Future research exploring social ecological interventions to assist pregnant women achieve optimal gestational weight gains are suggested to expand the evidence base.     

Midwives’ role in the provision of maternal and childhood immunisation information

ProblemInactivated influenza vaccine and diphtheria-tetanus acellular pertussis vaccine are routinely recommended during pregnancy to protect women and their babies from infection. Additionally, the hepatitis B vaccine is recommended for infants within the first week of life; however, little is known about midwives’ experiences of recommending and delivering these immunisations.BackgroundMidwives are a trusted source of vaccine information for parents and the confident provision of information about immunisation during antenatal clinic visits has been found to increase the uptake of antenatal and childhood vaccines.AimThis study aims to explore midwives’ experiences of discussing maternal and childhood immunisation with women and their partners and their confidence in answering parent’s questions.MethodsWe conducted 23 semi-structured interviews with registered Australian midwives working in public and private hospital settings, and in private practice.FindingsMidwives find negotiating the requirement to recommend immunisation within a women-centred framework challenging at times. The vast majority of midwives described their education on immunisation as inadequate and workplace issues, such as time pressure, were identified as further barriers to effective communication about immunisation.Discussion/conclusionThe provision of immunisation training within midwifery education and continued professional development is critical. Appropriately resourcing midwives with the necessary infrastructure, education and resources to fully inform parents about immunisation may have a positive impact on vaccine uptake.     

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.     

“It Makes My Skin Crawl”: Women’s experience of breastfeeding aversion response (BAR)

ProblemSome women who intend to breastfeed experience a breastfeeding aversion response (BAR) while breastfeeding.BackgroundLittle is known about the experience of those who have feelings of aversion while breastfeeding.AimThis study aimed to investigate the experiences of women who have an aversion response to breastfeeding while their infant is latched at the breast. This is the first study that aims to understand this breastfeeding aversion response (BAR) as described by women who experience this phenomenon.MethodsInterpretative phenomenological analysis (IPA) was used to conduct and analyse ten semi-structured in-depth interviews with women who self-identified as experiencing BAR.FindingsFour overarching themes were identified: (1) Involuntary, strong sensations of aversion in response to the act of breastfeeding, (2) Internal conflict and effects on maternal identity, (3) The connection between BAR and relationships with others, and (4) Reflections on coping with BAR and building resilience.DiscussionSome women who intend to breastfeed can experience BAR, and this negative sensation conflicts with their desire to breastfeed. BAR can impact on maternal wellbeing. Those who experience BAR may benefit from person-centred support that directly addresses the challenges associated with BAR to achieve their personal breastfeeding goals.ConclusionThe experience of BAR is unexpected and difficult for mothers. If support is not available, BAR can have detrimental effects on maternal identity, mother–child bonds, and intimate family relationships.     

Who decides the position for birth? A follow-up study of a randomised controlled trial

BackgroundPhysical benefits are suggested for women and their babies when women adopt an upright position of their choice at birth. Available care options during labour influence women's impressions of what intrapartum care is. This indicates that choice of birth positions may be determined more by midwives than by women's preferences.QuestionThe aims of this study were to investigate factors associated with adherence to allocated birth position and also to investigate factors associated with decision-making for birth position.MethodAn invitation to answer an on-line questionnaire was mailed.FindingsDespite being randomised, women who gave birth on the seat were statistically significantly more likely to report that they participated in decision-making and that they took the opportunity to choose their preferred birth position. They also reported statistically significantly more often than non-adherers that they felt powerful, protected and self-confident.ConclusionsMidwives should be conscious of the potential impact that birth positions have on women's birth experiences and on maternal outcomes. Midwives should encourage women's autonomy by giving unbiased information about the birth seat. An upright birth position may lead to greater childbirth satisfaction. Women's experience of and preferences for birth positions are consistent with current evidence for best practice.     

The maternal health-related issues that matter most to women in Ireland as they transition to motherhood - A qualitative study

BackgroundMany studies on women’s maternity care experiences reveal recurring issues that are poor or less than optimal. Women’s opinions on the maternal health-related issues that matter most to them are essential if care and services are to be improved.AimsTo identify the maternal health-related issues that matter most to women in Ireland, based on their own experiences of maternity care, services and motherhood.MethodsA qualitative exploratory study with 24 women. Following university ethical approval, audio-recorded one-to-one telephone interviews were conducted and thematically analysed.FindingsWe identified two themes, each with four subthemes, connected to a central concept of the invisible woman. Pendulum of care, and subthemes Inconsistent services, All about the baby, Induced anxiety and Information seesaw, illustrated the extremes of care and services that women experienced. Magnitude of motherhood, and subthemes Weight of responsibility, Real-time reassurance, Change of identity and Growth into advocacy, depicted the intensity of their new role while transitioning to motherhood.DiscussionFindings articulate the issues that mattered most to women in Ireland as they transitioned to motherhood. Some women identified specific research topics/areas, but all of the issues identified can be translated into researchable topics that seek to improve local care and service provision.ConclusionGiven the recurring nature of women’s less than satisfactory experiences of aspects of maternity care in many countries, it is likely that conducting research on issues that matters most to women will have the greatest impact on their health, wellbeing and lives as they transition to motherhood.     

Statistical modeling of selected aspects of the childbearing process with application to world fertility survey countries∗

The childbearing process should be monitored in developing countries experiencing high population growth rates and high levels of maternal and infant mortality. A mathematical model for estimation of certain aspects of the childbearing process, which requires only data on age‐specific fertility rates, is developed. Synthetic maternal childbearing indices, namely, mean ages at first and last birth, length of reproductive life span, inter‐birth spacing, and proportion of childless women, in addition to the well‐known mean age at childbearing, for the WFS countries are obtained using the proposed model. The indices are free from age truncation effects, and, under certain assumptions, provide information about a cohort's completed fertility before the women stop reproducing. The effects of women's residence and education on fertility are also examined.     

Adherence to three different strategies to prevent early onset GBS infection in newborns

ProblemDespite the introduction of preventive guidelines, no decrease in the incidence of early onset infection was observed.BackgroundEarly onset group B streptococcal (EOGBS) infection is an important cause of neonatal morbidity and mortality.AimOur study was conducted to determine adherence to three guideline-based group B streptococcus (GBS) preventive strategies.MethodsA prospective experimental study clustered by obstetric collaboration region was performed between March 2013 and August 2014 among midwives, obstetricians and paediatricians in the Netherlands. At baseline, the three regions operated according to the Dutch preventive strategy (founded on the risk-based strategy) in order to prevent EOGBS infection, whereas in the study period they followed either the risk-based, the combination or the Dutch strategy. Adherence was measured prospectively per pregnant woman, using predefined core elements of each preventive strategy: identification of risk factors, maternal GBS screening, application of intrapartum antibiotic prophylaxis and observation of the child. Data about adherence to the core elements were collected from medical records, maternal questionnaires and laboratory test results.FindingsIn the three regions, a total of 121 care providers and 1562 women participated.We found an overall adherence of 90% to the risk-based strategy, 57% to the combination strategy and 89% to the Dutch strategy. Adherence to a strategy in case women had EOGBS risk factors was below 20% in all strategies.DiscussionThe majority of women with EOGBS risk factors did not receive the care prescribed by any of three preventive strategies and were not treated optimally.ConclusionThe risk-based and the Dutch strategy are the recommended strategies for implementation.     

Childbirth evacuation among rural and remote Indigenous communities in Canada: A scoping review

ProblemRoutine evacuation of pregnant Indigenous women from remote regions to urban centres for childbirth is a central strategy for addressing maternal health disparities in Canada. Maternal evacuation continues despite mounting evidence of its negative impacts on Indigenous women and families.BackgroundSince the 1960s, pregnant Indigenous women living in remote regions in Canada have been transferred to urban hospitals for childbirth. In the following decades, evidence emerged linking maternal evacuation with negative impacts on Indigenous women, their families, and communities. In some communities, resistance to evacuation and the creation of local birthing facilities has resulted in highly diverse experiences of childbirth and evacuation.AimA scoping review mapped the evidence on maternal evacuation of Indigenous women in Canada and its associated factors and outcomes from 1978 to 2019.MethodsWe searched MEDLINE, Embase, and CINAHL, and grey literature from governmental and Indigenous organizations. We collated the evidence on maternal evacuation into 12 themes.ResultsFactors related to evacuation include (a) evacuation policies (b) institutional coercion (c) remoteness and (d) maternal-fetal health status. Evacuation-related outcomes include (e) maternal-child health impacts (f) women’s experience of evacuation (g) financial hardships (h) family disruption (i) cultural continuity and community wellness (ij) engagement with health services (k) self-determination, and (l) quality of health services.DiscussionNumerous emotional, social and cultural harms are associated with evacuation of Indigenous women in Canada. Little is known about the long-term impacts of evacuation on Indigenous maternal-infant health. Evidence on evacuation from remote Métis communities remains a critical knowledge gap.     

A narrative review of studies addressing the clinical effectiveness of perinatal depression screening programs

BackgroundClinical practice guidelines recommend that women be screened for depression as a routine component of maternity care however there is ongoing debate about the benefits of depression screening programs in this context.AimThis narrative review identifies and describes the clinical effectiveness of perinatal depression screening programs in relation to one or more of the following interrelated domains: referral for additional mental health support or treatment; engagement with mental health support or treatment options; and, maternal mental health or parenting outcomes.MethodsEnglish-language studies, published up to July 2017, were identified and their methodological quality was assessed. RCTs and non-RCTs were included.ResultsOverall, the majority of the fourteen studies identified showed that participation in a perinatal depression screening program increases referral rates and service use, and is associated with more optimal emotional health outcomes. One of four available studies demonstrated an improvement in parenting outcomes as a result of participation in an integrated postnatal depression screening program.ConclusionThis small but important body of work is integral to the continuing debate over the merits of screening for depression in the perinatal period. Current evidence favours the overall benefits of perinatal depression screening programs across the three focus areas of this review. Future research should consider a woman’s broader psychosocial context and should address the economic as well as clinical outcomes of these programs. Rigorous evaluation of emerging digital approaches to perinatal depression screening is also required.     

“You’re a ‘high-risk’ customer”: A qualitative study of women’s experiences of receiving information from health professionals regarding health problems or complications in pregnancy

BackgroundExperiencing complications in pregnancy is stressful for women and can impact on fetal and maternal outcomes. Supportive encounters with health professionals can reduce the worry women experience. Further research is needed to understand women’s perspectives on communicating with their healthcare providers about their concerns.AimThis study explored women’s experiences of receiving information about pregnancy complications from healthcare providers and their interactions with multiple professionals and services during pregnancy.MethodsThis was a qualitative interpretive study. Semi-structured interviews were conducted with 20 women experiencing pregnancy complications recruited from antenatal services at two hospitals in Sydney. Inductive thematic analysis was used to analyse the data.FindingsWomen had a range of reactions to their diagnoses, including concern for their baby, for themselves and for their labour. Most women reported that communication with healthcare providers was distressing, they were not listened to and staff used insensitive, abrupt language. Women were also distressed by delays in education, receiving contradictory information and having to repeatedly share their stories with different health professionals. In some cases, this damaged the therapeutic relationship and reduced trust towards healthcare providers. Midwives were generally preferred over doctors because they had a more woman-centred approach.ConclusionTo improve women’s experiences of care for pregnancy complications, it is critical to improve the communication skills of maternity service providers. Women’s need for information, resources and support can best be provided by continuity of care with a named health professional, for example, a midwife working within an integrated multidisciplinary antenatal service model.     

Effect of body image on gestational weight gain in overweight and obese women

Problem or backgroundThere is little information available describing how women who are overweight or obese in pregnancy perceive their bodies, and in particular the effect of body image dissatisfaction on gestational weight gain.QuestionTo describe how women who are overweight or obese in pregnancy perceive their body, and the effect of body image on gestational weight gain.MethodsThis prospective nested cohort study evaluated self estimation of body weight, preferred body shape, dieting behavior, satisfaction with body weight and shape, and gestational weight gain in pregnant women who were overweight or obese, through self-completed questionnaire in early pregnancy in South Australia from October 2010 to February 2012.FindingsOf the 442 women who completed the questionnaire, 25.8% correctly identified their BMI, with 70.1% under-estimating and 4.1% over-estimating their BMI. Women who were obese were significantly less likely to correctly identify their BMI, as were younger women. Women who incorrectly identified their BMI were significantly more likely to have higher gestational weight gain (P < 0.001). Approximately 45% of women indicated dissatisfaction with their weight or body shape, with this being more common in women of higher parity and higher BMI. Dissatisfaction was significantly related to gestational weight gain.ConclusionWomen who report increasing dissatisfaction with their body size and shape are more likely to gain excessive weight during pregnancy. Further research should explore insights about maternal body image and diet related behaviors.