Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda

Background

Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period.

Methods

This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention.

Discussion

There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions.

Trial registration

Pan African Clinical Trial Registry (www.pactr.org): PACTR202006793783148. Registered on 17th June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07155-z.

The Privilege of Information-An Examination of the Defence of Therapeutic Privilege and its Implications for Pregnant Women

Though apparently in existence across common law countries, the defence of 'therapeutic privilege' receives scant judicial analysis in case law. The extent of its reach is unclear and its underpinning justification is shaky. Often it forms a throwaway remark or poorly explored caveat when the duty of a physician to disclose information is being examined, rather than receiving any detailed judicial scrutiny in its own right. Furthermore, despite references to it in case law, it is questionable if it has ever successfully been invoked as a defence in either England and Wales or Ireland. This piece examines this lack of clarity and the often-vague references to the existence of therapeutic privilege in both case law and professional guidelines, followed by a consideration of why the defence may be particularly problematic and unjustified in the context of childbirth and the immediate postpartum period. Considering the dangers of therapeutic privilege in pregnancy presents a timely opportunity to examine the issues with the use of the defence in all other healthcare contexts, focusing particularly on its impact on individual patient autonomy. Finally, this piece concludes by contending that therapeutic privilege ought to be abolished, if it truly exists at all.

The Fear of Childbirth and Social Support in Adolescent Pregnancy

OBJECTIVE

Social support may be effective in alleviating fear associated with childbirth in pregnant adolescent women. This study was conducted to determine the relationship between social support and fear of childbirth in adolescent pregnancy.

DESIGN

The study was designed to assess any relationships between the social support perceived by pregnant adolescent women and the fear of childbirth that they experienced. through a cross-sectional analysis.

SETTING

The study was carried out in the obstetrics outpatient clinics of a public hospital.

PATIENTS

The study was conducted with 100 pregnant adolescents.

MEASUREMENTS

A personal information form, the Multidimensional Scale for Perceived Social Support (MSPSS), and the Wijma Birth Expectancy/Experience Scale Version A (WDEQ-A) were applied for data collection. The Pearson correlation coefficient was used to determine relationships between 2 continuous variables.

RESULTS

There was a significant negative correlation between the mean scores on the MSPSS and the WDEQ-A (r = -0.345, P < .01). The MSPSS score was found to be associated with gestational age, residence area, and type of marriage. The WDEQ-A score was associated with educational status.

CONCLUSION

The results demonstrate that social support is highly important for pregnant adolescents, especially considering the fact that the social support received from the spouse was relatively lower among adolescent women with lower gestational age. Nurses should evaluate the family of the pregnant adolescent, especially their partner, in terms of the social support that they provide to the pregnant woman and should support these women with necessary counseling.

Prenatal insomnia and childbirth-related PTSD symptoms: A prospective population-based cohort study

BACKGROUND

Certain populations are at high risk of experiencing a traumatic event and developing post-traumatic stress disorder (PTSD). Yet, primary preventive interventions against PTSD are lacking. It is therefore crucial to identify pre-traumatic risk factors, which could be targeted with such interventions. Insomnia may be a good candidate, but studies on civilians are sparse. Furthermore, the mechanisms at stake in the relationship between pre-traumatic insomnia and PTSD symptoms are unclear.

METHODS

This prospective population-based cohort study (n = 1,610) examined the relationship between insomnia symptoms at 32 weeks of pregnancy and childbirth-related PTSD (CB-PTSD) symptoms at eight weeks postpartum. Postnatal insomnia symptoms, prenatal psychological symptoms (depression, anxiety, PTSD, fear of childbirth), subjective birth experience (SBE) and birth medical severity were included as covariates in the analyses, which were based on a Piecewise Structural Equation Modelling approach.

RESULTS

The relationship between prenatal insomnia and CB-PTSD symptoms was mediated by negative SBE and postnatal insomnia symptoms. All relationships involving insomnia symptoms had small or very small effect sizes.

LIMITATIONS

This study used self-report questionnaires. Postnatal insomnia and CB-PTSD symptoms were concurrently measured.

CONCLUSION

Prenatal insomnia symptoms may impair the ability to cope with a difficult birth experience and contribute to postnatal insomnia, a risk factor for CB-PTSD. Thus, prenatal insomnia symptoms may be a promising target for CB-PTSD primary preventive interventions, although other prenatal psychological symptoms could also be considered. Even beyond the perinatal context, future studies on pre-traumatic insomnia and PTSD should include post-traumatic insomnia as a covariate.

'Stories of distress versus fulfilment': A narrative inquiry of midwives' experiences supporting alternative birth choices in the UK National Health Service

BACKGROUND

Some childbearing women/birthing people prioritize out of maternity care organizational guidelines' approaches to childbirth as a way of optimizing their chances of a normal physiological birth. Currently, there is little known about the experiences of midwives who support their choices.

AIM

To explore the experiences of UK midwives employed by the NHS, who self-defined as supportive of women's alternative physiological birthing choices.

METHODS

A narrative inquiry was used to collect and analyse professional stories of practice via self-written narratives and interviews. Forty-five midwives from across the UK were recruited.

FINDINGS

Three overarching storylines were developed with nine sub-themes. 'Stories of distress' highlights challenging experiences due to poor supportive working environments, ranging from small persistent challenges to extreme situations. Conversely, 'Stories of fulfilment' offers a positive counter-narrative where midwives worked in supportive working environments enabling woman-centred care unencumbered by organisational constraints. 'Stories of transition' abridge these two polarized themes.

CONCLUSION

The midwives' experiences were mediated by their socio-cultural working contexts. Negative experiences were characterised by a misalignment between the midwives' philosophy and organisational cultures, with significant consequences for the midwives. Conversely, examples of good organisational culture and practice reveal that it is possible for organisations to fulfil their obligations for safe and positive maternity care for both childbearing women who make alternative birthing choices, and for attending staff. This highlights what is feasible and achievable within maternity organisations and offers transferable insights for organisational support of out-of-guideline care that can be adapted across the UK and beyond.

Family life starts at home: Fathers' experiences of a newly implemented Swedish home-based postnatal care model - an interview study

OBJECTIVE

To explore and describe fathers' experiences of a newly implemented Swedish home-based postnatal care model.

DESIGN

A descriptive cross-sectional qualitative study was conducted as a part of a larger study.

SETTING

Families who qualified to be discharged early were offered to participate in a postnatal home-based model of midwifery care by a hospital in Stockholm, Sweden.

PARTICIPANTS AND MEASUREMENTS

In total, 16 fathers participated in a semi-structured telephone interview, averaging 43 min. Data were analyzed using systematic text condensation.

FINDINGS

Three major themes emerged: To decide on home- or hospital-based postnatal care - a matter of safety, To be offered professional midwifery postnatal support at home, and To be at home helped fathers to navigate parenthood. Fathers appreciated the home-based postnatal care and felt safe because of the received professional support from midwives.

KEY CONCLUSIONS

Home-based postnatal care was valued by fathers whose partner had a non-complicated vaginal birth because they felt safe in their home environment and supported by midwives. The home environment aided fathers in supporting their partners and developing a father-infant bond.

IMPLICATIONS FOR PRACTICE

Home-based postnatal care was valued by fathers and should be considered an option for new families. To offer home-based postnatal care may result in less overcrowded postnatal wards. Midwives need to enable fathers' participation and support their parental role regardless of where the care takes place.

Cumulative incidence of urinary incontinence and associated factors during pregnancy and after childbirth: a cohort study

INTRODUCTION AND HYPOTHESIS

This study examined the associated factors (i.e., obstetric and maternal-newborn factors) related to cumulative incidence of urinary incontinence and changes in urinary incontinence during pregnancy and the first year postpartum.

METHODS

This prospective, longitudinal, within-subject study included 501 women who completed the Incontinence Questionnaire-Urinary Incontinence Short Form during pre-pregnancy, early pregnancy, mid-pregnancy, and late pregnancy and at five time points during the first year postpartum. Data were analyzed by multivariate logistic regression, McNemar's and analysis of variance (ANOVA) tests.

RESULTS

According to the multivariate analysis, the gestational week and number of previous vaginal deliveries increased the risk of cumulative incidence of urinary incontinence (CIUI) during pregnancy (both p < 0.05). Full-time employment, higher body mass index, vaginal delivery and UI during early pregnancy and mid-pregnancy increased the risk of CIUI during the first year postpartum (all p < 0.05). CIUI tended to increase throughout the entire pregnancy (p < 0.001) and decrease from 3 to 5 days to 6 months postpartum (p = 0.028). The prevalence rates of UI at all postpartum visits were lower than those during late pregnancy (p < 0.001-0.009) but higher than those during pre-pregnancy (p < 0.001).

CONCLUSIONS

The results identified the change patterns in UI and the risk factors associated with CIUI during the entire pregnancy (i.e., gestational age and number of previous vaginal deliveries) and the first year postpartum (i.e., full-time work, higher body mass index, vaginal delivery and UI during early and mid-pregnancy). Appropriate counseling should be provided to women preparing for pregnancy and during the prenatal and postpartum periods.

Long-term evaluation of the impact of delivery modalities on anal continence in women with Crohn's disease

CONTEXT

Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied.

GOAL

The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD.

METHODS

A retrospective study was performed in women with CD who gave birth in a French "Level 3" maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score≥9 or a St. Mark's score≥9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses.

RESULTS

Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR=8.89, 95% (CI: 1.03-76.57) and crude OR=4.16, 95% (CI: 1.06-16.27) respectively for AI defined by the Wexner score, and crude OR=6.8, 95% (CI: 1.30-35.41) and crude OR=4.3, 95% (CI: 1.23-15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR=22.86, 95% CI: 1.52-931.28 for a Wexner score≥9 and adjusted OR=16. 11 (95% CI: 1.43-533.26) for a St Mark score≥9).

CONCLUSION

Vaginal birth was associated with the development of severe long-term AI in women with CD.

Comparison of early postnatal clinical outcomes of newborns born to pregnant women with COVID-19: a case-control study

BACKGROUND

The ongoing COVID-19 pandemic has infected millions of people, including pregnant women and newborns and caused many deaths. Studies examining the effects of COVID-19 infection in pregnancy have mostly focused on maternal outcomes and there are limited data on neonatal outcomes.

OBJECTIVES

This study aims to compare the early postnatal period clinical outcomes of newborns born to pregnant women with and without COVID-19.

METHODS

A retrospective case-control study was used to compare the clinical characteristics of newborns born to pregnant women with and without COVID-19. This study was conducted between 11 March 2020 and 11 March 2021 at Denizli State Hospital, Turkey. This study included 202 newborns selected with a nonprobability method. The clinical records and laboratory results of 202 newborns were reviewed by applying a retrospective questionnaire. Neonatal outcomes were compared between the groups.

RESULTS

There were 101 newborns born to pregnant women with COVID-19 in the case group and 101 without COVID-19 in the control group in the study. A considerably higher rate of newborns born to pregnant women with COVID-19 had cesarean delivery (79.2 versus 35.6%, p < .001), premature birth (28.7 versus 10.9%, p = .001), low birth weight (15.8 versus 6.9%, p = .046), neonatal respiratory distress syndrome (RDS) (37.6 versus 19.8%, p = .005), oxygen need (19.8 versus 37.6, p = .005), and neonatal intensive care unit admission (10.9 versus 37.6%, p = .001). Breastfeeding (1.0 versus 67.3%, p < .001) and nutrition with breast milk rates (33.7 versus 80.2%, p < .001) of newborns born to pregnant women with COVID-19 were significantly lower. The results of 101 newborns who received nasopharyngeal swab samples for COVID-19 were negative.

CONCLUSION

Newborns born to pregnant women with COVID-19 were more likely to experience preterm birth, cesarean delivery, low birth weight, neonatal RDS, oxygen demand, need for intensive care, and breastfeeding problems. There was no vertical contamination according to the nasopharyngeal swab samples of the newborns.

Making good care essential: The impact of increased obstetric interventions and decreased services during the COVID-19 pandemic

Problem & background

Since the onset of the COVID-19 pandemic in Canada, policies have been implemented to limit interpersonal contact in clinical and community settings. The impacts of pandemic-related policies on experiences of pregnancy and birth are crucial to investigate and learn from.

Aim

To examine the impact of pandemic policy changes on experiences of pregnancy and birth, thereby identifying barriers to good care; to inform understandings of medicalization, care, pregnancy, and subjectivity during times of crisis; and to critically examine the assumptions about pregnancy and birth that are sustained and produced through policy.

Methods

Qualitative descriptive study drawing on 67 in-depth interviews with people who were pregnant and/or gave birth in Canada during the pandemic. The study took a social constructionist standpoint and employed thematic analysis to derive meaning from study data.

Findings

The pandemic has resulted in an overall scaling back of perinatal care alongside the heavy use of interventions (e.g., induction of labour, cesarian section) in response to pandemic stresses and uncertainties. Intervention use here is an outcome of negotiation and collaboration between pregnant people and their care providers as they navigate pregnancy and birth in stressful, uncertain conditions.

Discussion

Continuity of care throughout pregnancy and postpartum, labour support persons, and non-clinical services and interventions for pain management are all essential components of safe maternal healthcare. However, pandemic perinatal care demonstrates that they are not viewed as such.

Conclusion

The pandemic has provided an opportunity to restructure Canadian reproductive health care to better support and encourage out-of-hospital births – including midwife-assisted births – for low-risk pregnancies.

Factors associated with health facility utilization during childbirth among 15 to 49-year-old women in Uganda: evidence from the Uganda demographic health survey 2016

BACKGROUND

Almost all maternal deaths and related morbidities occur in low-income countries. Childbirth supervised by a skilled provider in a health facility is a key intervention to prevent maternal and perinatal morbidity and mortality. Our study aimed to establish the factors associated with health facility utilization during childbirth in Uganda.

METHODS

We used the Uganda Demographic and Health Survey 2016 data of 10,152 women aged 15 to 49 years. The study focused on their most recent live birth in 5 years preceding the survey. We applied multistage stratified sampling to select study participants and we conducted multivariable logistic regression to establish the factors associated with health facility utilization during childbirth, using SPSS (version 25).

RESULTS

The proportion of women who gave birth at a health facility was 76.6% (7780/10,152: (95% confidence interval, CI, 75.8-77.5). The odds of women aged 15-19 years giving birth at health facilities were twice as those of women aged 40 to 49 years (adjusted odds ratio, AOR = 2.29; 95% CI: 1.71-3.07). Residing in urban areas and attending antenatal care (ANC) were associated with health facility use. The odds of women in the northern region of Uganda using health facilities were three times of those of women in the central region (AOR = 3.13; 95% CI: 2.15-4.56). Women with tertiary education (AOR = 4.96; 95% CI: 2.71-9.11) and those in the richest wealth quintile (AOR = 4.55; 95% CI: 3.27-6.32) had higher odds of using a health facility during child birth as compared to those with no education and those in the poorest wealth quintile, respectively. Muslims, Baganda, women exposed to mass media and having no problem with distance to health facility had higher odds of utilizing health facilities during childbirth as compared to Catholic, non Baganda, women not exposed to mass media and those having challenges with distance to access healthcare.

CONCLUSION

Health facility utilization during childbirth was high and it was associated with decreasing age, increasing level of education and wealth index, urban residence, Northern region of Uganda, ANC attendance, exposure to mass media, tribe, religion and distance to the nearby health facility. We recommend that interventions to promote health facility childbirths in Uganda target the poor, less educated, and older women especially those residing in rural areas with less exposure to mass media.

Predictors of fear of childbirth and depressive symptoms among pregnant women: a cross-sectional survey in Pwani region, Tanzania

BACKGROUND

Many women experience fear of childbirth (FoB) and depressive symptoms (DS) during pregnancy, but little is known about FoB among Tanzanian women. The current study aimed to assess the prevalence of FoB and DS among pregnant women and determine predictors of each and both, focusing on sociodemographic and obstetric predictors.

METHODS

A cross-sectional study was conducted at six health facilities in two districts in Tanzania between 2018 and 2019. In total, 694 pregnant women with gestational age between 32 and 40 weeks and expecting vaginal delivery were consecutively recruited and assessed for FoB and DS. We collected data through interviews using 6 and 4-points Likert Scale of the Wijma Delivery Expectancy Questionnaire Version A and Edinburgh Postnatal Depression Scale, respectively. Women who scored ≥66 and ≥ 10 were categorised as having FoB and DS, respectively. We performed multivariable logistic regression to investigate the predictors of FoB and DS.

RESULTS

The prevalence rates of FoB and DS among pregnant women were 15.1 and 17.7%, respectively. FoB and DS were more likely in women aged above 30 years [Adjusted Odds Ratio (AOR) 6.29, 95%CI 1.43-27.84] and in single mothers (AOR 2.57, 95%CI 1.14-5.78). Women with secondary education and above (AOR 0.22, 95%CI 0.05-0.99) and those who had given birth previously (AOR 0.27, 95% CI 0.09-0.87) were less likely to have FoB in combination with DS Women who had previous obstetric complications, and those who did not receive any social support from male partners in previous childbirth were more likely to have FoB and DS. FoB was strongly associated with DS (AOR 3.42, 95%CI 2.12-5.53). DS only was more common in women who had inadequate income (AOR 2.35, 95%CI 1.38-3.99) or had previously experienced a perineal tear (AOR 2.32, 95%CI 1.31-4.08).

CONCLUSIONS

Not having a formal education, having only primary education, being aged above 30 years, being single, being nulliparous, having experienced obstetric complications, and having a lack of social support from a male partner during previous pregnancy and childbirth were predictors of FoB and DS during pregnancy. FoB and DS were strongly associated with each other. It is vital to identify at-risk women early, to offer support during pregnancy and childbirth.

Adverse events in women giving birth in a labor ward: a retrospective record review study

Background

Childbirth could negatively affect the woman’s health through adverse events. To prevent adverse events and increase patient safety it is important to detect and learn from them. The aim of the study was to describe adverse events, including the preventability and severity of harm during planned vaginal births, in women giving birth in the labor ward.

Methods

The study had a descriptive design with a retrospective birth record review to assess the preventability of adverse events using the Swedish version of the Global Trigger Tool. The setting was a labor ward in Sweden with low-risk and risk childbirths. Descriptive statistics, Pearson’s Chi-square test and Student’s t-test were used.

Results

A total of 38 adverse events (12.2%) were identified in 311 reviewed birth records. Of these, 28 (73.7%) were assessed as preventable. Third- or fourth-degree lacerations and distended urinary bladder were most prevalent together with anesthesia-related adverse events. The majority of the adverse events were classified into the harm categories of ‘prolonged hospital care’ (63.2%) and ‘temporary harm’ (31.6%). No permanent harm were identified, but over two-thirds of the adverse events were assessed as preventable.

Conclusions

This first study using Global Trigger Tool in a labor ward in Sweden identified a higher incidence of adverse events than previous studies in obstetric care. No permanent patient harm was found, but over two-thirds of the adverse events were assessed as preventable. The results draw particular attention to 3^rd-or 4^th-degree lacerations, distended urinary bladder and anesthesia-related adverse events. The feedback on identified adverse events should be used for systematic quality improvement and clinical recommendations how to prevent adverse events must be implemented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07109-5.

First-time fathers' experience of childbirth: a cross-sectional study

OBJECTIVES

The purposes of this study are to report first-time fathers' experiences of childbirth through three dimensions (professional support, worries and prenatal preparation) and to analyse the influence of sociodemographic, antenatal and obstetrical factors on the three dimensions.

SETTING

Participants were recruited in France and Switzerland from two university hospitals that routinely manage high-risk pregnancies (level 3 - perinatal care level), with 4,000 to 5,000 annual births each.

METHODS

This is a secondary analysis of a cross-sectional study. The data initially were collected for the cross-cultural validation of the First-Time Father Questionnaire (FTFQ) into French. Descriptive statistics were used to report the participants' characteristics and their questionnaire responses. Multivariate linear regression analysis was carried out to stress the positive or negative factors linked with fathers' experiences of childbirth.

FINDINGS

Among 350 first-time fathers, 160 completed the FTFQ (response rate of 45.7%). The average age of the participants was 33 years old. We observed 12 questionnaire items with more than 20% unfavourable responses, seven of which involved the measurement of the worry dimension. Antenatal education and the prenatal-preparation dimension were positive factors linked with fathers' experiences. In addition, 57% of participants reported using one means of antenatal education, and 45% accessed information from family or friends.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The results suggest that first-time fathers need more professional support to foster positive experiences of childbirth. Their experiences of childbirth are associated with considerable worry. Antenatal classes specifically for fathers could reduce this worry and support the fatherhood process. Research should be carried out on these topics.

Prospective risk from prenatal anxiety to post traumatic stress following childbirth: The mediating effects of acute stress assessed during the postnatal hospital stay and preliminary evidence for moderating effects of doula care

OBJECTIVE

Growing literature has identified childbirth as a potentially traumatic event, following which mothers may develop symptoms of Post-Traumatic-Stress-Following-Childbirth. The current study is the first to prospectively examine a pathway of risk from mothers' prenatal trait-anxiety, to Acute-Stress-Immediately-Following-Childbirth, and later symptoms of Post-Traumatic-Stress-Following-Childbirth, in a low-risk community sample. Auxiliary analyses explored whether doula care during childbirth moderated risk.

METHOD

149 pregnant women were randomly selected. Prenatal trait-anxiety was assessed toward the end of pregnancy, Acute-Stress-Immediately-Following-Childbirth at two-days post-partum, and symptoms of Post-Traumatic-Stress-Following-Childbirth at one-month post-partum.

RESULTS

Results indicated a significant indirect pathway from prenatal trait-anxiety to Post-Traumatic-Stress-Following-Childbirth, through Acute-Stress-Immediately-Following-Childbirth. Two groups were generated ad hoc for auxiliary analyses: participants who opted to receive doula care during childbirth (n=21; 14%) versus participants who received care as usual (n=128; 86%). Analyses provided preliminary support for doula care as a potential moderator of risk.

CONCLUSIONS

Results point toward prenatal trait-anxiety and Acute-Stress-Immediately-Following-Childbirth as significant risk factors for Post-Traumatic-Stress-Following-Childbirth. Findings inform preventive screening implicating the prenatal period as well as the postnatal hospital stay as important time windows for preventive screening. Finally, preliminary support for moderating effects of doula care suggest that preventive interventions administered during the perinatal period may effectively reduce anxiety-related risk for Post-Traumatic-Stress-Following-Childbirth.

Postpartum depression and postpartum post-traumatic stress disorder: prevalence and associated factors

BACKGROUND

Despite the increased global interest from researchers in postpartum depression (PPD) and postpartum post-traumatic stress disorder (PP-PTSD), studies of PPD in China have shown a wide range of variability. Indeed, the prevalence and risk factors for PP-PTSD have received little attention in China.

AIM

To determine the prevalence of PPD and PP-PTSD in China, and to examine the relationships between a range of sociodemographic, pregnancy-related, and newborn-related variables, and PPD and PP-PTSD.

METHODS

A cross-sectional study involving 1136 women who returned to the obstetrics clinic for routine postpartum examination were enrolled. The sociodemographic, pregnancy-related, and newborn-related characteristics were collected. Social support, and PPD and PP-PTSD symptoms were measured by the Perceived Social Support Scale (PSSS), the Edinburgh Postnatal Depression Scale (EPDS), and the Perinatal Post-traumatic Stress Questionnaire (PPQ).

RESULTS

The prevalence rates of PPD and PP-PTSD symptoms were 23.5 and 6.1%, respectively. A multivariate model showed that the presence of PP-PTSD was the strongest risk factor for PPD symptoms and vice versa. Other risk factors for PPD included low sleep quality, low social support and newborn's incubator admission. In terms of PP-PTSD symptoms, risk factors included the presence of PPD symptoms, non-Han ethnicity, and low social support, while having one child was a protective factor.

CONCLUSIONS

This study addressed some gaps in the literature and provided a better understanding of PPD and PP-PTSD in China, which may contribute to early detection and intervention. Attention should be paid to women who are most susceptible to PPD and/or PP-PTSD, including those with low social support, low sleep quality, newborn's incubator admission, non-Han ethnicity, and women with siblings.

Factors influencing women's perceptions of choice and control during pregnancy and birth: a cross-sectional study

BACKGROUND

Women across the world value choice and control throughout their maternity care experiences. In response to this health policy and frameworks are adapting and developing. The concepts of choice and control are extrinsically complex and open to interpretation by healthcare professionals and service users, with the two not necessarily aligning. Depending on a number of factors, women's experiences of choice and control within the same maternity care system may be very different. This study aimed to investigate the factors influencing women's perceptions of choice and control during pregnancy and birth in Ireland.

METHODS

We conducted a cross-sectional study using an adapted version of the UK national maternity experience survey (National Perinatal Epidemiology Unit). During March - July 2017, a sample of 1277 women were recruited from the postnatal wards of three maternity units and a tertiary maternity hospital. Poisson regression was used to assess the association between twelve factors and a series of measures of the women's perception of choice and control.

RESULTS

Most women reported not having choice in the model or location of their maternity care but most reported being involved enough in decision-making, especially during birth. Women who availed of private maternity care reported higher levels of choice and control than those who availed of public maternity care. This factor was the most influential factor on almost all choice and control measures.

CONCLUSION

Most women experiencing maternity care in Ireland report not having choice in the model and location of care. These are core elements of the Irish maternity strategy and significant investment will be required if improved choice is to be provided. Availing of private maternity care has the strongest influence on a woman's perceived choice and control but many women cannot afford this type of care, nor may they want this model of care.

Fathers' involvement in perinatal healthcare in Australia: experiences and reflections of Ethiopian-Australian men and women

Background

Family-centred maternity care models include the expectation that fathers prepare for and attend the birth. In Australia over 20% of the population is from a culturally and linguistically diverse background. Public policies espouse culturally competent healthcare. Little is known about the experiences of perinatal health care of men from culturally and linguistically diverse (CALD) communities living in high income countries. The aim was to understand the experiences, attitudes and beliefs about father’s inclusion in perinatal healthcare, from the growing, and recently settled community of Ethiopian families living in Australia.

Methods

A qualitative study using semi-structured individual interviews with Ethiopian-Australian men and women who had experienced Australian maternity care and were sampled for diversity of time since migration, and parity. Interviews were in English, audio-recorded, transcribed and then analysed thematically.

Results

Participants were seven women and six men all born in Ethiopia, including two couples. Key themes included: the loss of extended family through migration, new roles for both parents and the need to establish ‘family-like’ relationships with friendship groups in Australia. There was a willingness to involve male partners in the Ethiopian community in Australia, although it was recognised as a cultural change. Experiences of male partner involvement were mixed among healthcare types, with men attending Maternal and Child Health (MCH) appointments less frequently than antenatal (ANC) appointments.

Conclusions

Results suggests men may be missing out on the education provided during antenatal appointments and may benefit from an alternative. There were not universally high levels of cultural competency among healthcare professionals, with further training still required. Commitment to paid employment remains a barrier to men’s involvement, suggesting that flexible working conditions and increased paternity leave would support their involvement. Alternatively services could utilise flexible delivery methods such as phone and zoom to include fathers.

Edible Medicinal Plants on Facilitating Childbirth: A Systematic Review

BACKGROUND

Despite advances and the availability of newer drugs to facilitate childbirth, the interest in using natural treatments is on the rise. More than 20 percent of pregnancies require induction of labor, which is associated with side effects and increased risk of cesarean surgery. For this reason, the use of medicinal plants is considered healthier.

OBJECTIVE

The present study is a systematic review of the role of oral herbs in facilitating childbirth.

METHOD

This review was conducted via searching the Medline/PubMed, Google Scholar, Scopus, and SID databases. The review began systematically and with no time constraints. It lasted until December 29, 2020.

RESULTS

Twenty clinical trials investigated the impact of edible plants on increasing cervical readiness, stimulating labor onset, reducing pain intensity, and shortening the duration of labor. Five studies have revealed the positive impact of saffron. Two studies reported the same effect by chamomile. Three studies showed the positive impact of boiled dill seeds, and two studies showed the impact of date and date syrup. Another study reported the impact of Descurainia Sophia, and six studies also showed the positive effect of castor oil on uterine stimulation, strengthening and relieving labor pains, which eventually lead to facilitating labor. One study also showed no improvement in bishop score after consumption of primrose capsules.

CONCLUSION

The positive effect of edible medicinal plants on facilitating childbirth has been shown in the mentioned studies. However, more studies with a larger sample size are needed, and there is also a need for a more detailed study of the possible mechanisms of plant effects.

Frequency and severity of prehospital obstetric events encountered by emergency medical services in the United States

Background

Prehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US.

Methods

We conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider’s impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen’s kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations.

Results

A total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen’s kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS).

Conclusion

Prehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04129-1.

Comparison of fear, anxiety and self-efficacy of childbirth among primiparous and multiparous women

Background

The aim of this study was to compare fear of childbirth, state and trait anxiety, and childbirth self-efficacy among primiparous and multiparous women in Ahvaz, southwest of Iran.

Methods

This cross-sectional study was conducted with 200 pregnant women (100 primiparous and 100 multiparous women) who had been admitted to the maternity ward of hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. The instruments used for data collection in this study included a demographic questionnaire, Delivery Fear Scale (DFS), Spielberger's State-Trait Anxiety Inventory (STAI), and Childbirth Self-Efficacy Inventory (CBSEI). The data were analyzed by chi-square test and independent t-test. Also, the univariate general linear model was used by adjusting for the socio-demographic and obstetric characteristics that were considered as possible confounding variables.

Results

The mean score of DFS in primiparous women was significantly higher than that of multiparous women. The mean of the overall score of childbirth self-efficacy of primiparous women was significantly lower than that of multiparous women. The mean score of the outcome expectancies and self-efficacy expectancies was significantly lower in primiparous women compared with multiparous women. There was no statistically significant difference between the two groups in terms of the mean score of STAI. After adjusting for possible confounding variables, the differences between the two groups in terms of fear of childbirth scores, overall childbirth self-efficacy score and self-efficacy expectancies remained significant.

Conclusion

Given the high fear of childbirth and low childbirth self-efficacy in primiparous women compared to the multiparous women, appropriate interventions should be adopted by health care providers in order to reduce fear and improve childbirth self-efficacy in primiparous women.

Predictors for sexual dysfunction in the first year postpartum: a systematic review and meta-analysis

BACKGROUND

Pregnancy and childbirth increase the risk for pelvic floor dysfunction, including sexual dysfunction. So far, the mechanisms and the extent to which certain risk factors play a role remain unclear.

OBJECTIVES

In this systematic review of the literature we aimed to determine risk factors for sexual dysfunction in the first year after childbirth.

SEARCH STRATEGY

We searched MEDLINE, Embase and CENTRAL using the search strategy: sexual dysfunction AND obstetric events.

SELECTION CRITERIA

We included original, comparative studies, reported in English, that used validated questionnaires and the ICS/IUGA terminology for sexual dysfunction, dyspareunia and vaginal dryness.

DATA COLLECTION AND ANALYSIS

We assessed the quality and the risk of bias of the included studies with the Newcastle-Ottawa scale. We extracted the reported data and we performed random-effects meta-analysis to obtain the summary odds ratios (ORs) with 95% confidence intervals (95% CIs). Heterogeneity across studies was assessed using the I² statistic.

MAIN RESULTS

Anal sphincter injury was associated with increased odds for both sexual dysfunction (OR 3.00, 95%CI 1.28-7.03) and dyspareunia (OR 1.92, 95% CI 1.47-2.52). Episiotomy was associated with dyspareunia (OR 1.64, 95% CI 1.25-2.14), but not with sexual dysfunction (OR 1.90, 95% CI 0.94-3.84). Compared with spontaneous birth, caesarean section reduced the odds for dyspareunia (OR 0.68, 95% CI 0.54-0.86) but not for sexual dysfunction (OR 1.14, 95% CI 0.89-1.46). Instrumental vaginal birth increased the odds for sexual dysfunction (OR 1.70, 95% CI 1.05-2.76), yet no difference was found for dyspareunia (OR 1.82, 95% CI 0.88-3.75). One study of low quality reported on vaginal dryness and found no association with obstetric events.

CONCLUSIONS

Perineal trauma, rather than mode of birth, increases the odds for sexual dysfunction in the first year after childbirth.

TWEETABLE ABSTRACT

Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy.

Childbirth with epidural analgesia in a pregnant woman with hypokalemic periodic paralysis

Familial hypokalaemic periodic paralysis (FHPP) is an uncommon genetic disease characterized by muscle weakness associated with hypokalaemia. Episodes are precipitated by drugs, stress, metabolic diseases, hypothermia or infection. We report the case of a 38-year-old pregnant women with FHPP who underwent epidural analgesia for labour. Pregnant women with FHPP require multidisciplinary management involving an anaesthesiologist, a gynaecologist and a paediatrician. It is important to maintain normothermia, prevent hyperventilation, monitor electrolytes, avoid glucose infusions and medications that cause hypokalaemia, and administer potassium supplements when required. Locoregional techniques should be preferred over general anaesthesia. Early epidural analgesia reduces the risk of pain that could trigger an episode of FHPP. In the case of general anaesthesia, drugs that can cause malignant hyperthermia should be avoided, and short-acting non-depolarizing neuromuscular blockers with blockade-depth monitoring should be used.

The impact of COVID-19 on the provision of respectful maternity care: Findings from a global survey of health workers

Background

Significant adjustments to maternity care in response to the COVID-19 pandemic and the direct impacts of COVID-19 can compromise the quality of maternal and newborn care.

Aim

To explore how the COVID-19 pandemic negatively affected frontline health workers’ ability to provide respectful maternity care globally.

Methods

We conducted a global online survey of health workers to assess the provision of maternal and newborn healthcare during the COVID-19 pandemic. We collected qualitative data between July and December 2020 among a subset of respondents and conducted a qualitative content analysis to explore open-ended responses.

Findings

Health workers (n = 1127) from 71 countries participated; and 120 participants from 33 countries provided qualitative data. The COVID-19 pandemic negatively affected the provision of respectful maternity care in multiple ways. Six central themes were identified: less family involvement, reduced emotional and physical support for women, compromised standards of care, increased exposure to medically unjustified caesarean section, and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures. Further, respectful care provided to women and newborns with suspected or confirmed COVID-19 infection was severely affected due to health workers’ fear of getting infected and measures taken to minimise COVID-19 transmission.

Discussion

Multidimensional and contextually-adapted actions are urgently needed to mitigate the impacts of the COVID-19 pandemic on the provision and continued promotion of respectful maternity care globally in the long-term.

Conclusions

The measures taken during the COVID-19 pandemic had the capacity to disrupt the provision of respectful maternity care and therefore the quality of maternity care.

Mobility for maternal health among women in hard-to-reach fishing communities on Lake Victoria, Uganda; a community-based cross-sectional survey

BACKGROUND

Maternal mortality is still a challenge in Uganda, at 336 deaths per 100,000 live births, especially in rural hard to reach communities. Distance to a health facility influences maternal deaths. We explored women's mobility for maternal health, distances travelled for antenatal care (ANC) and childbirth among hard-to-reach Lake Victoria islands fishing communities (FCs) of Kalangala district, Uganda.

METHODS

A cross sectional survey among 450 consenting women aged 15-49 years, with a prior childbirth was conducted in 6 islands FCs, during January-May 2018. Data was collected on socio-demographics, ANC, birth attendance, and distances travelled from residence to ANC or childbirth during the most recent childbirth. Regression modeling was used to determine factors associated with over 5 km travel distance and mobility for childbirth.

RESULTS

The majority of women were residing in communities with a government (public) health facility [84.2 %, (379/450)]. Most ANC was at facilities within 5 km distance [72 %, (157/218)], while most women had travelled outside their communities for childbirth [58.9 %, (265/450)]. The longest distance travelled was 257.5 km for ANC and 426 km for childbirth attendance. Travel of over 5 km for childbirth was associated with adolescent girls and young women (AGYW) [AOR = 1.9, 95 % CI (1.1-3.6)], up to five years residency duration [AOR = 1.8, 95 % CI (1.0-3.3)], and absence of a public health facility in the community [AOR = 6.1, 95 % CI (1.4-27.1)]. Women who had stayed in the communities for up to 5 years [AOR = 3.0, 95 % CI (1.3-6.7)], those whose partners had completed at least eight years of formal education [AOR = 2.2, 95 % CI (1.0-4.7)], and those with up to one lifetime birth [AOR = 6.0, 95 % CI (2.0-18.1)] were likely to have moved to away from their communities for childbirth.

CONCLUSIONS

Despite most women who attended ANC doing so within their communities, we observed that majority chose to give birth outside their communities. Longer travel distances were more likely among AGYW, among shorter term community residents and where public health facilities were absent.

TRIAL REGISTRATION

PACTR201903906459874 (Retrospectively registered). https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5977 .

Payment mechanism for institutional births in Nepal

BACKGROUND

Since the Millennium Development Goal era, there have been several efforts to increase institutional births using demand side financing. Since 2005, Government of Nepal has implemented Maternity Incentive Scheme (MIS) to reduce out of pocket expenditure (OOPE) for institutional birth. We aim to assess OOPE among women who had institutional births and coverage of MIS in Nepal.

METHOD

We conducted a prospective cohort study in 12 hospitals of Nepal for a period of 18 months. All women who were admitted in the hospital for delivery and consented were enrolled into the study. Research nurses conducted pre-discharge interviews with women on costs paid for medical services and non-medical services. We analysed the out of pocket expenditure by mode of delivery, duration of stay and hospitals. We also analysed the coverage of maternal incentive scheme in these hospitals.

RESULTS

Among the women (n-21,697) reporting OOPE, the average expenditure per birth was 41.5 USD with 36 % attributing to transportation cost. The median OOPE was highest in Bheri hospital (60.3 USD) in comparison with other hospitals. The OOPE increased by 1.5 USD (1.2, 1.8) with each additional day stay in the hospital. There was a difference in the OOPE by mode of delivery, duration of hospital-stay and hospital of birth. The median OOPE was high among the caesarean birth with 43.3 USD in comparison with vaginal birth, 32.6 USD. The median OOPE was 44.7 USD, if the women stayed for 7 days and 33.5 USD if the women stayed for 24 h. The OOPE increased by 1.5 USD with each additional day of hospital stay after 24 h. The coverage of maternal incentive was 96.5 % among the women enrolled in the study.

CONCLUSIONS

Families still make out of pocket expenditure for institutional birth with a large proportion attributed to hospital care. OOPE for institutional births varied by duration of stay and mode of birth. Given the near universal coverage of incentive scheme, there is a need to review the amount of re-imbursement done to women based on duration of stay and mode of birth.

Postpartum Early EMDR therapy Intervention (PERCEIVE) study for women after a traumatic birth experience: study protocol for a randomized controlled trial

BACKGROUND

Up to 33% of women develop symptoms of posttraumatic stress disorder (PTSD) after a traumatic birth experience. Negative and traumatic childbirth experiences can also lead to fear of childbirth, avoiding or negatively influencing a subsequent pregnancy, mother-infant bonding problems, problems with breastfeeding, depression and reduced quality of life. For PTSD in general, eye movement desensitization and reprocessing (EMDR) therapy has proven to be effective. However, little is known about the preventive effects of early intervention EMDR therapy in women after a traumatic birth experience. The purpose of this study is to determine the effectiveness of early intervention EMDR therapy in preventing PTSD and reducing PTSD symptoms in women with a traumatic birth experience.

METHODS

The PERCEIVE study is a randomized controlled trial. Women suffering from the consequences of a traumatic birth experience will be randomly allocated at maximum 14 days postpartum to either EMDR therapy or 'care-as-usual'. Patients in the EMDR group receive two sessions of therapy between 14 (T0) and 35 days postpartum. All participants will be assessed at T0 and at 9 weeks postpartum (T1). At T1, all participants will undergo a CAPS-5 interview about the presence and severity of PTSD symptoms. The primary outcome measure is the severity of PTSD symptoms, whereas the secondary outcomes pertain to fear of childbirth, mother-infant bonding, breastfeeding, depression and quality of life. The study will be conducted at a large city hospital and at multiple midwifery practices in Amsterdam, the Netherlands.

DISCUSSION

It is to be expected that the results of this study will provide more insight about the safety and effectiveness of early intervention EMDR therapy in the prevention and reduction of PTSD (symptoms) in women with a traumatic birth experience.

TRIAL REGISTRATION

Netherlands Trial Register NL73231.000.20 . Registered on 21 August 2020.

Adequacy of prenatal care use among pregnant women with epilepsy: A population-based, cross-sectional study, Finland, 2000-2014

PURPOSE

To examine the association between epilepsy and frequency and time of initiation of prenatal care use among pregnant women in Finland.

METHODS

We conducted a nationally representative, population-based cross-sectional study including pregnant women with epilepsy in Finland between 2000-2014. Selected demographic and clinical data were obtained by linking multiple national health registers and census. Crude and adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression analysis. Effect modification of the main association was examined by parity.

RESULTS

We examined 10,798 and 921,873 women with and without epilepsy, respectively, and the two groups differed significantly on prenatal care constructs. Women with epilepsy were more likely to have 25 or more total prenatal visits (10.4 % vs. 5.8%) and earlier initiation of prenatal care (at <8 weeks of gestation) (30.8% vs. 24.7%) compared to women without epilepsy. Epilepsy was significantly associated with 25 or more prenatal care visits (aOR=1.84; 95% CI=1.71, 1.98). The association between epilepsy and early initiation of prenatal care (<8 weeks) was significantly modified by parity, where multiparous women had increased odds of early prenatal care initiation (aOR=1.32; 95% CI=1.24, 1.41) compared to nulliparous women (aOR=1.19; 95% CI=1.11, 1.28).

CONCLUSIONS

Finnish healthcare, which is publicly funded and freely accessible, provided pregnant women with epilepsy adequate and timely prenatal care. Parity modified the period when prenatal care was initiated as multiparous women were initiated early to receive prenatal care compared to nulliparous women.

Continuum of maternity care in Zambia: a national representative survey

Background

Globally, over half of maternal deaths are related to pregnancy-related complications. Provision of a continuum of care during pregnancy, childbirth and the postnatal period results in reduced maternal and neonatal morbidity and mortality. Hence this study determined the prevalence of the continuum of care and its determinants among women in Zambia.

Methods

We used weighted data from the Zambian Demographic and Health Survey (ZDHS) of 2018 for 7325 women aged 15 to 49 years. Multistage stratified sampling was used to select study participants. Complete continuum of care was considered when a woman had; at least four antenatal care (ANC) contacts, utilized a health facility for childbirth and had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression to explore continuum of care in Zambia. All our analyses were done using SPSS version 25.

Results

Of the 7,325 women, 38.0% (2787/7325) (95% confidence interval (CI): 36.9-39.1) had complete continuum of maternal healthcare. Women who had attained tertiary level of education (adjusted odds ratio (AOR): 1.93, 95% CI: 1.09-3.42) and whose partners had also attained tertiary level of education (AOR: 2.58, 95% CI: 1.54-4.32) were more likely to utilize the whole continuum of care compared to those who had no education. Women who initiated ANC after the first trimester (AOR: 0.46, 95% CI: 0.39-0.53) were less likely to utilize the whole continuum of care compared to those who initiated in the first semester. Women with exposure to radio (AOR: 1.58, 95% CI: 1.27-1.96) were more likely to utilize the whole continuum of care compared to those who were not exposed to radio. Women residing in the Western province were less likely to utilize the entire continuum of care compared to those in the other nine provinces.

Conclusion

Level of education of the women and of their partners, early timing of ANC initiation, residing in other provinces other than the Western province, and exposure to information through radio were positively associated with utilization of the entire continuum of care. Improving literacy levels and promoting maternity services through radio may improve the level of utilization of maternity services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04080-1.

Non-pharmacological interventions to reduce anxiety in pregnancy, labour and postpartum: A systematic review

BACKGROUND

The anxiety mothers experience during pregnancy is well known and may have negative consequences for the emotional, psychological, and social development of newborns. Anxiety must therefore be reduced using different strategies.

OBJECTIVE

To determine published non-pharmacological interventions to reduce anxiety during pregnancy, childbirth and postpartum.

METHODS

A systematic peer-review of experimental and quasi-experimental studies was conducted using the PubMed, Scopus, Web of Science (WOS), and CINAHL databases. The quality of the studies was assessed using the Spanish version of the PEDro scale. Two researchers participated independently in the data selection and extraction process.

FINDINGS

587 articles were identified, of which 21 met the eligibility criteria. In eleven studies the intervention was performed during pregnancy, in three of them during labour, in four of them during the postpartum period, and in three of them during pregnancy and postpartum. During pregnancy, the most effective interventions were behavioural activation, cognitive behavioural therapy, yoga, music therapy, and relaxation; during childbirth: aromatherapy; during pregnancy and postpartum: antenatal training, massage by partners, and self-guided book reading with professional telephone assistance.

CONCLUSION AND IMPLICATIONS

The most effective interventions to reduce anxiety were performed either during pregnancy or during the postpartum period, not during labour. Most of the interventions were performed on the women, with few of them being performed on both partners. Non-pharmacological interventions may be applied by nurses and midwives to reduce anxiety during pregnancy, labour and postpartum.

Relationships among lesbians involved in childbirth/parenting, sperm donors, and children in Japan

This study clarified how lesbians access sperm, give birth, and raise children considering the Japanese cultural context and their relationships with sperm donors and children. Fieldwork data were obtained from an active self-help organization that comprises sexual minorities who want to have children or are already parents. Data were collected from February 2018 to November 2020. Lesbian couples sought to obtain sperm in several ways, including from domestic or overseas sperm banks, friends/acquaintances, friendship marriage websites, matching events, and blood relatives. My research revealed that the weakest legal relationship between sperm donors and children was when sperm was purchased from overseas sperm banks, specifically, whether a child knows his or her origin depends on whether his or her mother had purchased anonymous or non-anonymous sperm. At the other end of the spectrum was friendship marriage. If a lesbian and a gay manget married and have a child, the child is legally a child of both people-just like in a heterosexual relationship. However, my research showed that raising children and living together in a friendship marriage was associated with a myriad of problems. In sum, the sperm donor-child relationship can be very unclear; therefore, both donors and recipients must be prepared for various risks before women decide to give birth and raise a child. Japanese policymakers should promptly establish relevant laws to address these issues, starting with the recognition of same-sex marriage.

Childbirth violence-based negative health consequences: a qualitative study in Iranian women

BACKGROUND

Violation of mothers' rights during childbirth is a global problem that often silently torments women in many parts of the world. The aim of this study was to explore negative health consequences due to childbirth violence based on mothers' perceptions and experiences.

METHODS

To achieve rich data, an exploratory qualitative study was carried out in 2019 on 26 women with childbirth violence experience who had given birth in hospitals of Ilam, Iran. Data were collected using semi‑structure in‑depth interviews (IDIs) and a purposive sampling. Participants were asked about their experiences and perceptions of negative health consequences due to childbirth violence. Data were analyzed by conventional content analysis based on Graneheim and Lundman approach. MAXQDA (v.18) software was used for better data management.

RESULTS

Final codes were classified into 9 sub-categories and 3 main categories including maternal and newborn injuries, weakening of family ties, sense of distrust and hatred. These findings emerged the theme: negative health consequences.

CONCLUSIONS

This study broke the silence of abused mothers during childbirth and expressed the perspective of mothers who suffered childbirth violence as a routine phenomenon in maternal care, and a serious threat to the health of mothers, newborns and families. Findings of this study can be a warning for maternity health system, monitoring and support structures as well as health policy-makers to seriously plan to prevent and eliminate this problem.

Perturbed nuptiality, delayed fertility: childbirth effects of Covid19

An aspect of the Covid-19 pandemic that merits attention is its effects on marriage and childbirth. Although the direct fertility effects of people getting the virus may be minor, the impact of delayed marriages due to the first preventive lockdown, such as that imposed in Pakistan from March 14 to May 8 2020, and the closure of marriage halls that lasted till September 14 may be non-negligible. These demographic consequences are of particular import to developing countries such as Pakistan where birth rates remain high, marriage is nearly universal, and almost all child-bearing takes place within marriage. Based on historic marriage patterns, we estimate that the delay in nuptiality during the first wave of the coronavirus outbreak may affect about half of the marriages that were to take place during the year. In Pakistan, childbearing begins soon after marriage, and about 37% of Pakistani married women give birth to their first child within twelve months of marriage. A sizeable number out of these, around 400,000 annual births that occur within twelve months of the marriage, may consequently be delayed. Postponement of marriages due to the accompanying difficult economic situation and employment precariousness will accentuate this fertility effect. The net fertility impact of the Covid-19 outbreak will ultimately depend not only on the delay in marriages but also on the reproductive behavior of existing couples.

Modelling the cost of place of birth: a pathway analysis

BACKGROUND

In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown.

OBJECTIVES

The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective.

METHODS

This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year.

FINDINGS

496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth.

CONCLUSION

The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.

'I know my place'; a meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries

OBJECTIVE

During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities,face barriers in accessing care,and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries.

METHODS

A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020.

FINDINGS

A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, 'Prejudiced and deindividualized care', 'Interpersonal relationships and interactions' and 'Creating and enhancing insecurities.' A line of argument synthesis entitled 'I know my place' encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as 'Being seen, being heard' acknowledging positive aspects of maternity care reported by women.

CONCLUSION

Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.

An innovative intervention to improve respectful maternity care in three Districts in Ethiopia

BACKGROUND

Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions.

METHODS

Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data.

RESULTS

Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations.

CONCLUSION

This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner.

Lived experiences of the partners of COVID-19 positive childbearing women: A qualitative study

Problem

Several maternity units worldwide have rapidly put in place changes to maternity care pathways and restrictive preventive measures in the attempt to limit the spread of COVID-19, resulting in birth companions often not being allowed to be present at birth and throughout hospital admission.

Background

The WHO strongly recommends that the emotional, practical, advocacy and health benefits of having a chosen birth companion are respected and accommodated, including women with suspected, likely or confirmed COVID-19.

Aim

To explore the lived experiences of the partners of COVID-19 positive childbearing women who gave birth during the first pandemic wave (March and April 2020) in a Northern Italy maternity hospital.

Methods

A qualitative study using an interpretive phenomenological approach was undertaken. Audio-recorded semi-structured interviews were conducted with 14 partners. Thematic data analysis was conducted using NVivo software. Ethical approval was obtained from the relevant Ethics Committee prior to commencing the study.

Findings

The findings include five main themes: (1) emotional impact of the pandemic; (2) partner and parent: a dual role; (3) not being present at birth: a ‘denied’ experience; (4) returning to ‘normality’; (5) feedback to ‘pandemic’ maternity services and policies.

Discussion and conclusion

Key elements of good practice to promote positive childbirth experiences in the context of a pandemic were identified: presence of a birth companion; COVID-19 screening tests for support persons; timely, proactive and comprehensive communication of information to support persons; staggered hospital visiting times; follow-up of socio-psychological wellbeing; antenatal and postnatal home visiting; family-centred policies and services.

Place and space in relation to childbirth: a critical interpretive synthesis

Background: In nursing and midwifery, the concept of environment is considered a meta-concept. Research findings suggest that the location is not the only important factor, as both place and space influence the practices of midwives. Moreover, research on the geography of health suggests a connection between place and health that could be extended to reproductive health. Therefore, to move beyond and expand traditional research expressions, it is beneficial to illuminate the concepts of place and space in relation to childbirth.

Purpose: This study was undertaken to produce a synthesis of previous qualitative research of issues in childbirth in relation to the concepts of place and space.

Method: In this Critical Interpretive Synthesis (CIS), four electronic databases; CINAHL, Medline, PsycINFO and Sociological abstracts, were used for the literature search. In total 734 papers were screened, and 27 papers met the final inclusion criteria after assessment.

Results: The synthesis reveals a need to create a space for childbirth underpinned by four aspects; a homely space, a spiritual space, a safe space, and a territorial space.

Conclusion: Findings from this review will provide a basis for useful dialogue in midwifery education and in clinical settings.

Changes in alcohol consumption during pregnancy and over the transition towards parenthood

OBJECTIVE

To examine pre- to postnatal changes in drinking for women and men and assess the role of education level in these changes.

BACKGROUND

The transition towards parenthood can contribute to significant shifts in alcohol consumption for women and men. Research has generally focused on pregnancy and short-term changes following childbirth, usually for mothers only. Socio-economic variation in the impact of childbirth and return to drinking postnatally is similarly understudied.

METHOD

Longitudinal alcohol consumption data for 2470 individuals (1248 female) who were pregnant, or the partner of a pregnant woman, were obtained from a representative, Australian survey for three years prior and following birth. Piecewise regression models, including an education-x-time interaction, assessed changes in drinking quantity and frequency.

RESULTS

Female usual quantity and frequency significantly declined during pregnancy, followed by significant postnatal increases in quantity, approaching pre-pregnancy levels, with similar trends across education levels. Male usual quantity increased following childbirth, save for those men with a high-school education. Having an undergraduate degree was associated with a significant postnatal increase in drinking frequency.

CONCLUSION

Further awareness of the risks associated with male-partner drinking could provide substantial public health benefits. Successful facilitation and implementation of interventions and harm reduction strategies for harmful drinking over the pre- to postnatal period could benefit from further consideration of socioeconomic status and education level, particularly for men.

The influence and meaning of the birth environment for nulliparous women at a hospital-based labour ward in Sweden: An ethnographic study

BACKGROUND

Labour and birth are sensitive physiological processes substantially influenced by environmental and psychosocial factors.

AIM

To explore the influence and meaning of the birth environment for nulliparous women giving birth in either one of two differently designed birthing rooms at a hospital-based labour ward.

METHODS

Five months of ethnographic fieldwork was conducted at a labour ward in Sweden, consisting of participant observations of 16 nulliparous women giving birth in either a 'Regular' birthing room (n = 8) or a specially designed, 'New room' (n = 8). Data included field notes, informal interviews, reflective notes, and individual interviews with eight women after birth. The data was analysed through an ethnographic iterative hermeneutic analysis process.

FINDINGS

The analysis identified the birth environment as consisting of the physical space, the human interaction within it, and the institutional context. The analytic concept; Birth Manual was conceived as an instrument for managing labour in accordance with institutional authority. Significant to the interpretation of the influence and meaning of the birth environment were two abstract rooms: an Institutional room, where birth was approached as a critical event, designating birthing women as passive; and a Personal room, where birth was approached as a physiological event in which women's agency was facilitated.

CONCLUSION

Institutional authority permeated the atmosphere within the birth environment, irrespective of the design of the room. A power imbalance between institutional demands and birthing women's needs was identified, emphasising the vital role the birth philosophy plays in creating safe birth environments that increase women's sense of agency.

Capturing women's voices: lived experiences of incivility during childbirth in the United States

Increasing research has improved global awareness of mistreatment during childbirth. However, research primarily focuses on "higher-intensity" mistreatment during childbirth, and largely focuses on women outside the United States (U.S.). We address these gaps by exploring the phenomenology of incivility, a "lower-intensity" mistreatment, experienced by women during childbirth in the U.S. We used a combination of interpretative phenomenological analysis (IPA) and thematic analysis to analyze the qualitative responses (N = 200) of experiences of incivility during childbirth. We identified nine primary themes of incivility: lack of empathy, denial/minimization, ignoring, pressure, privacy issues, breastfeeding/formula issues, identity-based, uncomfortable physical interactions, and silencing. Results demonstrate incivility is critical to consider as a form of mistreatment in childbirth because it violates respect. The results help nuance the understanding of how mistreatment is experienced in childbirth. Results also demonstrate unique manifestations of incivility were shaped by the sociopolitical context of the U.S. Implications for policy development and health outcomes are discussed.

Validating a scale to measure respectful maternity care in Australia: Challenges and recommendations

OBJECTIVE

Respectful maternity care is a pervasive human rights issue, but little is known about its realisation in Australia. Two scales, developed in North America, measure key aspects of respectful maternity care: the Mothers on Respect Index and Mothers Autonomy in Decision Making scale. This study aimed to validate these two scales in Queensland, Australia, and to determine the extent to which women currently experience respectful maternity care and autonomy in decision making.

DESIGN

A sequential two-phase study. A focus group reviewed the scales, made adaptations to scale items and completed a Content Validation Survey. The Respectful Maternity Care in Queensland survey, comprising the validated Australian scales and demographic questions was distributed online in early 2020.

SETTING

Queensland, Australia.

PARTICIPANTS

Focus group involved women (n=10) who were aged over 18, English-speaking, and had given birth during the preceding two years. All women who had birthed in Queensland between September 2019 and February 2020, were eligible to participate in the cross-sectional survey. 161 women participated in the survey.

MEASUREMENTS AND FINDINGS

Item content validity (>0.78) was established for all but one item. Scale content validity was established for both scales (0.92 and 0.99 respectively). Survey participants (n= 161) were mostly married/partnered (95%), heterosexual (93%), tertiary educated (47%), Caucasian (88%), and had experienced a range of maternity models of care. Median scores on each scale (74 and 26 respectively) indicated that participants felt well respected and highly autonomous. Free-text comments highlighted the importance of relationship-based care.

KEY CONCLUSIONS

Both scales appear valid for use in Australia. Although most participants reported high levels of respect and autonomy, the proportion of participants who had experienced continuity of midwifery care was also high.

IMPLICATIONS FOR PRACTICE

Both scales could be routinely deployed as patient reported experience measures in Australia, broadening the data that informs maternity service planning and delivery.

Proportion, Characteristics and Maternal Outcome of women referred for childbirth to a tertiary hospital in northern Tanzania - A descriptive retrospective study based on a hospital birth registry

OBJECTIVE

Timely identification of danger signs and prompt referral to higher level may prevent complication associated with childbirth. With a high MMR in Tanzania, there is need to highlight the information on the proportion of women referred to tertiary healthcare, their basic characteristics and outcomes. This study aimed to determine the proportion, basic characteristics and outcomes among women referred while in labour, from lower health facilities to a tertiary hospital in northern Tanzania.

METHODS

A descriptive retrospective study based on a hospital birth registry was conducted using consecutive stored data on pregnant women referred while in labour and managed at a tertiary hospital in northern Tanzania, between the years 2000 and 2015.

RESULTS

During the study period, a total of 53,662 deliveries were managed. Among these, 6066 women were referred from lower health facilities, with 4193 (69.2%) of them being referred while in labour. The main reason for referral was poor progress of labour (31.0%), followed by prolonged labour (27.1%) and obstructed labour (19.5%). The rate of caesarean section was 44.6%. A total of 292 maternal deaths occurred between 2000 and 2015. Of these, almost a quarter (22.6%) occurred in women referred from other health facilities while in labour.

CONCLUSION

Majority of referred women while in labour from lower health facilities are linked to maternal complications associated with childbirth. This underscores the need to further explore the competence of lower health facilities to quickly detect complications and provide effective emergency obstetric care, as well as timely referral to higher-level facility.

Lived experiences of women with maternal near miss: a qualitative research

OBJECTIVE

A near-miss experience has long-term and major impacts on mothers and their families. Therefore, evaluating the nature of maternal near-miss (MNM) could shed light on various aspects of the associated complications in women. The present study aimed to determine the lived experiences of women with MNM.

METHODS AND MATERIALS

This qualitative research was conducted using conventional content analysis on 10 mothers with an MNM experience, who were selected based on the inclusion criteria. Data were collected via semi-structured interviews about the experiences of the mothers during and after the near-miss incident. Data analysis was performed using the conventional content analysis technique.

RESULTS

Five main categories were extracted, including fears and concerns, failure to accept and adapt, tolerating physical and psychological pain and hardships, death experience, and medical team mismanagement. Regret and fear of raising the child with siblings, fear of the re-marriage of the spouse, and fear of complications and costs were among the subcategories of fears and concerns. Lack of adaptation to the complications and prolonged mourning were the subcategories of failure to accept and adapt, and the subcategories of tolerating physical and psychological pain and hardships were a sense of guilt, tolerating physical pain, hopelessness, irritability, hatred toward the medical team, and postpartum depression. In addition, returning to normal life, and seeing/actually feeling death were the subcategories of the death experience. The subcategories of the medical team mismanagement included medical errors, lack of support/negligence, communication problems, and distrust of the medical center.

DISCUSSION

According to the results, the mothers were faced with multiple problems, including fears and concerns, failure to adapt to the problem, and numerous physical and psychological issues after an MNM experience. However, they believed that medical errors, the improper communications of the medical team, and their negligence toward patients were among the factors intensifying the complications.

A qualitative study on professionals' attitudes and views towards the introduction of patient reported measures into public maternity care pathway

Background

The importance and potential benefits of introducing patient reported measures (PRMs) into health care service have been widely acknowledged, yet the experience regarding their implementation into practice is limited. There is a considerable paucity of research in adopting PRMs in maternity care routine. This study, which utilizes the PRMs included in Pregnancy and Childbirth (PCB) outcome set developed by International Consortium for Health Outcomes Measurement (ICHOM) as sample measures, aims to elicit Finnish professionals’ views on PRMs and to explore the applicability of PRMs in Finnish public maternity care.

Methods

This qualitative study, applying semi-structured interviews, described the local professionals’ views towards the application of PRMs in Finnish public maternity care. Professionals were asked to assess the PRMs defined in ICHOM PCB set and provide their expectations and concerns on the implementation of PRMs in Finnish public maternity service.

Results

Twenty professionals participated in the interviews. Participants agreed on the importance and relevance of the PRMs questions included in ICHOM PCB set for delivering and developing maternity care in Finland. However, they criticized the number and length of questions as well as the recommended time points of data collection. In addition, for a successful implementation, various steps like developing suitable questions, redesigning service pathway and protocols, and motivating women to respond to PRMs questions were considered to be important. Also, some potential obstacles, difficulties and risks associated with the implementation were underlined.

Conclusion

This study indicates that the implementation of PRMs into Finnish public maternity service is possible, highly relevant and important. However, the adoption of PRMs into routine practice may be challenging and will require a series of efforts. This study shows viewpoints from Finnish professionals who have not participated in developing the ICHOM PCB standard set and provides important insights on the development and implementation of PRMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06658-z.

Association between maternity waiting home stay and obstetric outcomes in Yetebon, Ethiopia: a mixed-methods observational cohort study

Background

A strategy for reducing adverse pregnancy outcomes is the expanded implementation of maternity waiting homes (MWHs). We assessed factors influencing MWH use, as well as the association between MWH stay and obstetric outcomes in a hospital in rural Ethiopia.

Methods

Data from medical records of the Glenn C. Olson Memorial Primary Hospital obstetric ward were cross matched with records from the affiliated MWH between 1 and 2011 to 31 March 2014. Poisson regression with robust variance was conducted to estimate the relative risk (RR) of childbirth complications associated with MWH use vs. non-use. Five key informant interviews of a convenience sample of three MWH staff and two users were conducted and a thematic analysis performed of social, cultural, and economic factors underlying MWH use.

Results

During the study period, 489 women gave birth at the hospital, 93 of whom were MWH users. Common reasons for using the MWH were post-term status, previous caesarean section/myomectomy, malposition/malpresentation, and low-lying placenta, placenta previa, or antepartum hemorrhage, and hypertension or preeclampsia. MWH users were more likely than non-users to have had a previous caesarean Sec. (15.1 % vs. 5.3 %, p < 0.001) and to be post-term (21.5 % vs. 3.8 %, p < 0.001). MWH users were also more likely to undergo a caesarean Sec. (51.0 % vs. 35.4 %, p < 0.05) and less likely (p < 0.05) to have a spontaneous vaginal delivery (49.0 % vs. 63.6 %), obstructed labor (6.5 % vs. 14.4 %) or stillbirth (1.1 % vs. 8.6 %). MWH use (N = 93) was associated with a 77 % (adjusted RR = 0.23, 95 % Confidence Interval (CI) 0.12–0.46, p < 0.001) lower risk of childbirth complications, a 94 % (adjusted RR = 0.06, 95 % CI 0.01–0.43, p = 0.005) lower risk of fetal and newborn complications, and a 73 % (adjusted RR = 0.27, 95 % CI 0.13–0.56, p < 0.001) lower risk of maternal complications compared to MWH non-users (N = 396). Birth weight [median 3.5 kg (interquartile range 3.0-3.8) vs. 3.2 kg (2.8–3.5), p < 0.001] and 5-min Apgar scores (adjusted difference = 0.25, 95 % CI 0.06–0.44, p < 0.001) were also higher in offspring of MWH users. Opportunity costs due to missed work and need to arrange for care of children at home, long travel times, and lack of entertainment were suggested as key barriers to MWH utilization.

Conclusions

This observational, non-randomized study suggests that MWH usage was associated with significantly improved childbirth outcomes. Increasing facility quality, expanding services, and providing educational opportunities should be considered to increase MWH use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03913-3.

Perinatal health care access, childbirth concerns, and birthing decision-making among pregnant people in California during COVID-19

Background

During public health emergencies, including the COVID-19 pandemic, access to adequate healthcare is crucial for providing for the health and wellbeing of families. Pregnant and postpartum people are a particularly vulnerable subgroup to consider when studying healthcare access. Not only are perinatal people likely at higher risk for illness, mortality, and morbidity from COVID-19 infection, they are also at higher risk for negative outcomes due to delayed or inadequate access to routine care.

Methods

We surveyed 820 pregnant people in California over two waves of the COVID-19 pandemic: (1) a ‘non-surge’ wave (June 2020, n = 433), and (2) during a ‘surge’ in cases (December 2020, n = 387) to describe current access to perinatal healthcare, as well as concerns and decision-making regarding childbirth, over time. We also examined whether existing structural vulnerabilities – including acute financial insecurity and racial/ethnic minoritization – are associated with access, concerns, and decision-making over these two waves.

Results

Pregnant Californians generally enjoyed more access to, and fewer concerns about, perinatal healthcare during the winter of 2020–2021, despite surging COVID-19 cases and hospitalizations, as compared to those surveyed during the COVID-19 ‘lull’ in the summer of 2020. However, across ‘surge’ and ‘non-surge’ pandemic circumstances, marginalized pregnant people continued to fare worse – especially those facing acute financial difficulty, and racially minoritized individuals identifying as Black or Indigenous.

Conclusions

It is important for clinicians, researchers, and policymakers to understand whether and how shifting community transmission and infection rates may impact access to perinatal healthcare. Targeting minoritized and financially insecure communities for increased upstream perinatal healthcare supports are promising avenues to blunt the negative impacts of the COVID-19 pandemic on pregnant people in California.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03942-y.

Reproducing fear: the effect of birth stories on nulligravid women's birth preferences

OBJECTIVE

Preference for caesarean birth is associated with higher fear and lower self-efficacy for vaginal birth. Vicarious experience is a strong factor influencing self-efficacy in nulligravid women, and is increasingly accessible via digital and general media. This study assessed the effect of exposure to different birth stories on nulligravid women's childbirth preferences and the factors mediating these effects.

METHODS

Nulligravid women (N = 426) were randomly allocated to one of four conditions exposing them to written birth stories. Stories varied by type of birth (vaginal/caesarean) and storyteller evaluation (positive/negative) in a 2 × 2 design. Childbirth preference, fear of labour and vaginal birth, and self-efficacy for vaginal birth were measured before and after exposure via a two-way between groups analysis of covariance. Hierarchical regression models were used to determine the mediating effects of change in childbirth fear and childbirth self-efficacy.

RESULTS

Variations in type of birth and storyteller evaluation significantly influenced childbirth preferences (F (1, 421) = 44.78, p < 0.001). The effect of vaginal birth stories on preference was significantly mediated by fear of labour and vaginal birth and self-efficacy. Effects of exposure to caesarean birth stories were not explained by changes in fear or self-efficacy.

CONCLUSIONS

Childbirth preferences in nulligravid women can be significantly influenced by vicarious experiences. For stories about vaginal birth, the influence of birth stories on women's fear and self-efficacy expectancy are partly responsible for this influence. The findings highlight the importance of monitoring bias in vicarious experiences, and may inform novel strategies to promote healthy childbirth.

Fear of childbirth in Iran: A systematic review of psychological intervention research

Background

Due to the fear of childbirth (FOC) and failure to provide painless delivery in Iran, the prevalence rate of elective cesarean section (C-section) performed on request by pregnant women is on the rise. However, no systematic review assessing the results of studies in this respect has been thus far developed.

Objective

To systematically review published psychological intervention research reflecting on FOC in Iran.

Materials and Methods

In this systematic review, the databases of PubMed, MEDLINE, PsycINFO, Wiley, ISI Web of Science, Scopus, Science Direct, Cochrane Library, Google Scholar, and Scientific Information Database were searched to retrieve the relevant studies. Manual searches were performed to find the relevant articles and finally 21 intervention studies were reviewed.

Results

Based on the modified Jadad Scale, a methodological quality (risk of bias) assessment tool, 14 and 7 studies had acceptable or good and low quality, respectively. The included articles covered fear, fear of childbirth, pregnancy, and psychological intervention in Iran. Cognitive behavioral therapy, relaxation techniques, psychological counseling, childbirth preparation classes (CPCs), mindfulness programs, and psychoeducation had been also practiced as the main types of psychological interventions for reducing FOC in pregnant women.

Conclusion

There was no clear evidence to establish the most effective method for minimizing levels of FOC in pregnant women. Based on the assessment tool and since most of the studies had moderate or low quality, conducting standard and high-quality randomized controlled trials focusing on FOC in pregnant women is of most importance in Iranian population.

Facility-level determinants of quality routine intrapartum care in Afghanistan

BACKGROUND

Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.

METHODS

We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.

RESULTS

Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.

CONCLUSIONS

Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.