Continuous support for women during childbirth

The effect of using birth ball and squatting position during labor on pain, duration, and satisfaction: A randomized controlled trial

AIM

The aim of this study is to assess the effect of using a birth ball and squatting position during labor on labor pain, duration of labor, and satisfaction.

METHODS

This study is a randomized controlled experimental trial. It was conducted in the delivery unit of Başakşehir Çam and Sakura City Hospital. The study sample consisted of a total of 159 women, 53 in the birth ball application room, 53 in the squatting position group, and 53 in the control group. The "Information Form," "Visual Analog Scale," "Partograph," and "Maternal Satisfaction Assessment at Delivery Scale-Normal Birth" were used in the data collection. Data were analyzed using analysis of variance, Pearson's Chi-square test, Pillai's trace test.

RESULTS

The present study revealed that the pain perception level was lower in the birth ball and squatting position groups compared to the control group, and there was a statistically significant difference between them (p < .05). The duration of the first and second stages of labor and the total duration of labor decreased in the birth ball and squatting position groups (p < .05). The difference was statistically significant in comparing the level of satisfaction (p < .05). It was found that the highest satisfaction was in the birth ball group.

CONCLUSION

Using a birth ball and squatting position during labor are effective methods of reducing labor pain, shortening the duration of labor, and increasing the level of satisfaction. There is a need for more studies on the effects of the birth ball and squatting position.

CLINICALTRIALS

gov Identifier: NCT05360823.

Prompting and Modeling of Coping Strategies during Childbirth

There is ample evidence to suggest that upright positions and mobility during labor improve birth outcome, including shorter duration of childbirth and reduced risk of cesarean section. The use of nonpharmacological interventions for pain management during childbirth are recommended by major health-care institutions and medical providers, however, the current methodologies for training coping strategies for use during labor have not shown to be effective on mobility or birth outcome. The purpose of this study was to apply an in-vivo teaching technology to the current childbirth model to prompt an imitative repertoire of empirically demonstrated labor coping strategies. Results of this study concluded that the introduction of a software using immediate prompting and video modeling increased the frequency and variability of labor behaviors during unmedicated labor for birthing persons and their partners.

Visualization of contractions: Evaluation of a new experience design concept to enhance the childbirth experience

BACKGROUND

The purpose of this study was to develop and evaluate an innovative design proposition intended to help enhance the childbirth experience. The innovation consists of a smartphone application for birth preparation during pregnancy with information and coaching, in addition to a wall projection at the labor ward that visualizes the progress of labor based on uterine monitoring data.

METHODS

We conducted a randomized controlled clinical pilot study. Singleton pregnant people pursuing a vaginal birth were recruited between 28 and 32 weeks of gestation and allocated to the intervention group (mobile application during the third trimester and wall projection at the labor ward) or to care as usual. Childbirth expectations and experiences were measured with validated questionnaires, which were completed at 32 and 36 weeks of gestation, immediately after birth, and at 4 weeks postpartum. Quantitative outcomes were analyzed and feedback about the proposition was evaluated using qualitative methods.

RESULTS

The qualitative feedback from patients was largely positive; however, we could not detect any significant differences between the intervention and control groups about fear of childbirth and other outcome measures.

CONCLUSION

In this pilot study, we evaluated a new experience design proposition for pregnancy and childbirth. This study generated data that will help to further improve and evaluate similar innovations in the future. This application may facilitate participatory care, promoting active involvement of parents in the healthcare processes of pregnancy and childbirth.

The obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic in Iran

BACKGROUND

Enhancing the quality of obstetric triage services requires a clear perception of the current situations and problems, this issue gained more importance during the COVID-19 pandemic. The purpose of this study was to explore the obstetric and gynecological service providers' and recipients' perception and experience of the quality of obstetric triage services during the COVID-19 pandemic.

METHODS

This research was a qualitative study carried out using conventional content analysis. Participants were selected through purposive sampling, and data collection was conducted using in-depth semi-structured interviews. Data were analyzed using MAXQDA software and conventional content analysis. Validity of the data was approved based on four criteria: credibility, dependability, conformability and transferability.

RESULTS

Five themes emerged through analysis: "unpreparedness to deal with the COVID-19 resulting in disorganized triage", "threat to the physical and mental health of personnel during the COVID-19 pandemic", "degradation of the quality of services due to improper triage structure during the COVID-19 pandemic", "communicating with patients which is neglected during the COVID-19 pandemic" and finally "accountability required to improve the provision of services during the COVID-19 pandemic.

CONCLUSION

Obstetrics and gynecology service providers and recipients faced formidable challenges in the triage department during this pandemic caused by the complex and ambiguous nature of the Coronavirus. Identifying the problems, barriers and challenges in providing services to patients in this situation especially in triage, can lead to an improvement in the outcome of services.

Experiences of giving birth during the COVID-19 pandemic: a qualitative analysis of social media comments through the lens of birth integrity

BACKGROUND

Social media offer women a space to discuss birth-related fears and experiences. This is particularly the case during the COVID-19 pandemic when measures to contain the spread of the virus and high rates of infection have had an impact on the delivery of care, potentially restricting women's rights and increasing the risk of experiencing different forms of mistreatment or violence. Through the lens of birth integrity, we focused on the experiences of women giving birth in Germany as shared on social media, and on what may have sheltered or violated their integrity during birth.

METHODS

Using thematic analysis, we identified key themes in 127 comments and associated reactions (i.e. "likes", emojis) posted on a Facebook public page in response to the dissemination of a research survey on maternity care in the first year of the COVID-19 pandemic.

RESULTS

Women contributing to the dataset gave birth during March and December 2020. They were most negatively affected by own mask-wearing -especially during the active phase of labour, not being allowed a birth companion of choice, lack of supportive care, and exclusion of their partner from the hospital. Those topics generated the most reactions, revealing compassion from other women and mixed feelings about health measures, from acceptation to anger. Many women explicitly formulated how inhumane or disrespectful the care was. While some women felt restricted by the tight visiting rules, those were seen as positive by others, who benefited from the relative quiet of maternity wards and opportunities for postpartum healing and bonding.

CONCLUSION

Exceptional pandemic circumstances have introduced new parameters in maternity care, some of which appear acceptable, necessary, or beneficial to women, and some of which can be considered violations of birth integrity. Our research calls for the investigation of the long-term impact of those violations and the reassessment of the optimal conditions of the delivery of respectful maternity during the pandemic and beyond.

The impacts of the COVID-19 pandemic on birth satisfaction and birth experiences in Russian women

Background

Women's satisfaction with their childbirth experiences has significant impacts on their health and the health of their children. Recently, childbirth and maternity care systems have been disrupted by the COVID-19 pandemic. This study aimed to investigate the association of birth satisfaction with mode of birth, medical interventions, support during labour, type of childbirth healthcare plan and antenatal education in the context of the COVID-19 pandemic in Russia.

Methods

1,645 Russian women who gave birth during the first year of the COVID-19 pandemic and 611 matched controls who gave birth in the previous year participated in an anonymous Internet survey about their childbirth experience. The survey included questions regarding women's demographic and obstetric characteristics as well as their childbirth experiences. Birth satisfaction was measured using the Birth Satisfaction Scale Revised Indicator (BSS-RI).

Results

Birth satisfaction scores did not show notable changes before and during the pandemic (Pearson Chi-square = 19.7, p = 0.22). Women had lower BSS-RI scores if they tested positive for COVID-19 during labour (F = 9.18, p = 0.002), but not during pregnancy or postpartum (p > 0.32). In both cohorts women who had vaginal births rated birth satisfaction higher than those who had caesarean births. The more medical interventions there were, the lower were the BSS-RI scores (B = -0.234, 95% CI: -0.760; -0.506, p < 0.001), but only during the pandemic. Birth satisfaction was higher if women had a support person present during labour (F > 7.44, p < 0.001), which was not possible for over 70% of participants during the pandemic. In both cohorts birth satisfaction was associated with the childbirth healthcare plan (F > 5.27, p < 0.001), but not with antenatal education (F < 0.15, p > 0.43).

Conclusions

Our study highlights the significant impacts of the COVID-19 pandemic on the birth experiences of Russian women. Sustaining the rights of women to informed decisions during labour, respect for their preferred childbirth healthcare plan, presence of the birth team of choice and professional support for home birth are essential for higher birth satisfaction and better health outcomes for mothers and their infants.

Advancing quality and safety of perinatal services in India: opportunities for effective midwifery integration

India has made significant progress in improving maternal and child health. However, there are persistent disparities in maternal and child morbidity and mortality in many communities. Mistreatment of women in childbirth and gender-based violence are common and reduce women's sense of safety. Recently, the Government of India committed to establishing a specialized midwifery cadre: Nurse Practitioners in Midwifery (NPMs). Integration of NPMs into the current health system has the potential to increase respectful maternity care, reduce unnecessary interventions, and improve resource allocation, ultimately improving maternal-newborn outcomes. To synthesize the evidence on effective midwifery integration, we conducted a desk review of peer-reviewed articles, reports and regulatory documents describing models of practice, organization of health services and lessons learned from other countries. We also interviewed key informants in India who described the current state of the healthcare system, opportunities, and anticipated challenges to establishing a new cadre of midwives. Using an intersectional feminist theoretical framework, we triangulated the findings from the desk review with interview data to identify levers for change and recommendations. Findings from the desk review highlight that benefits of midwifery on outcomes and experience link to models of midwifery care, and limited scope of practice and prohibitive practice settings are threats to successful integration. Interviews with key informants affirm the importance of meeting global standards for practice, education, inter-professional collaboration and midwifery leadership. Key informants noted that the expansion of respectful maternity care and improved outcomes will depend on the scope and model of practice for the cadre. Domains needing attention include building professional identity; creating a robust, sustainable education system; addressing existing inter-professional issues and strengthening referral and quality monitoring systems. Public and professional education on midwifery roles and scope of practice, improved regulatory conditions and enabling practice environments will be key to successful integration of midwives in India.

Birth Doula Care in California During COVID-19: The Impacts of Social Distancing on a High-Touch Helping Profession

Birth doulas were deemed "non-essential" personnel during the COVID-19 pandemic and were generally excluded from attending hospital births in person. This study documents the impacts of pandemic-related contextual factors on birth doula care in the San Francisco Bay Area, examines how doulas adapted their services, and explores implications for policy and practice. We employed a contextually bound qualitative case study methodology driven by social action theory and conducted interviews with 15 birth doulas. The pandemic disrupted physical settings, the social environment, communication modalities, contractual arrangements, and organizational level factors. The historical context also amplified awareness of institutionalized racism in birth settings and highlighted birth doulas' advocacy role. Striking deficits exist in birth doulas' integration into US healthcare systems; this made their services uniquely vulnerable to the pandemic circumstances. Birth doulas' value ought to be more formally recognized within health policy, health insurance, and hospital systems as complementary care to that provided by medical providers to improve access to high-quality perinatal care.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

The implementation process of the Confident Birth method in Swedish antenatal education: opportunities, obstacles and recommendations

Antenatal clinics in western Sweden have recently invested in a birth method called Confident Birth. In this study, we investigate midwives’ and first line managers’ perceptions regarding the method, and identify opportunities and obstacles in its implementation. Semi-structured individual interviews were conducted with ten midwives and five first line managers working in 19 antenatal clinics in western Sweden. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. Intervention Characteristics—such as perceptions about the Confident Birth method—were found to have equipped the midwives with coping strategies that were useful for expecting parents during birth. Outer Setting—the method was implemented to harmonize the antenatal education, and provided a mean for a birth companionship of choice. Inner setting—included time-consuming preparations and insufficient information at all levels, which affected the implementation. Characteristics of individuals—, such as knowledge and believes in the method, where trust in the method was seen as an opportunity, while long experience of teaching other birth preparatory methods, affected how the Confident Birth method was perceived. Process—such as no strategy for ensuring that the core of the method remained intact or plans for guiding its implementation were major obstacles to successful implementation. The findings speak to the importance of adequate planning, time, information and communication throughout the process to have a successful implementation. Based on lessons learned from this study, we have developed recommendations for successful implementation of interventions, such as the Confident Birth, in antenatal care settings.

Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation

Background

Global disparities in maternal mortality could be reduced by universal facility delivery. Yet, deficiencies in the quality of care prevent some mothers from seeking facility-based obstetric care. Obstetric care navigators (OCNs) are a new form of lay health workers that combine elements of continuous labor support and care navigation to promote obstetric referrals. Here we report qualitative results from the pilot OCN project implemented in Indigenous villages in the Guatemalan central highlands.

Methods

We conducted semi-structured interviews with 17 mothers who received OCN accompaniment and 13 staff—namely physicians, nurses, and social workers—of the main public hospital in the pilot’s catchment area (Chimaltenango). Interviews queried OCN’s impact on patient and hospital staff experience and understanding of intended OCN roles. Audiorecorded interviews were transcribed, coded, and underwent content analysis.

Results

Maternal fear of surgical intervention, disrespectful and abusive treatment, and linguistic barriers were principal deterrents of care seeking. Physicians and nurses reported cultural barriers, opposition from family, and inadequate hospital resources as challenges to providing care to Indigenous mothers. Patient and hospital staff identified four valuable services offered by OCNs: emotional support, patient advocacy, facilitation of patient-provider communication, and care coordination. While patients and most physicians felt that OCNs had an overwhelmingly positive impact, nurses felt their effort would be better directed toward traditional nursing tasks.

Conclusions

Many barriers to maternity care exist for Indigenous mothers in Guatemala. OCNs can improve mothers’ experiences in public hospitals and reduce limitations faced by providers. However, broader buy-in from hospital staff—especially nurses—appears critical to program success. Future research should focus on measuring the impact of obstetric care navigation on key clinical outcomes (cesarean delivery) and mothers’ future care seeking behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03842-1.

FIGO good clinical practice paper: management of the second stage of labor

This good clinical practice paper provides an overview of the current evidence around second stage care, highlighting the challenges and the importance of maintaining high-quality, safe, and respectful care in all settings. It includes a series of recommendations based on best available evidence regarding length of second stage, judicious use of episiotomy, and the importance of competent attendants and adequate resource to facilitate all aspects of second stage management, from physiological birth to assisted vaginal delivery and cesarean at full dilatation. The second stage of labor is potentially the most dangerous time for the baby and can have significant consequences for the mother, including death or severe perineal trauma or fistula, especially where there are failures to recognize and repair. This paper sets out principles of care, including the vital role of skilled birth attendants and birth companions, and the importance of obstetricians and midwives working together effectively and speaking with one voice, whether to women or to policy makers. The optimization of high-quality, safe, and personalized care in the second stage of labor for all women globally can only be achieved by appropriate attention to the training of birth attendants, midwives, and obstetricians. FIGO is committed to this aim alongside the WHO, ICM, and all FIGO's 132 member societies.

Motherhood in the Time of Coronavirus: The Impact of the Pandemic Emergency on Expectant and Postpartum Women's Psychological Well-Being

The birth of a child is a critical and potentially stressful experience for women, entailing several changes both at the individual and interpersonal level. This event can lead to different forms of distress, ranging in intensity and duration. Many studies highlighted medical, psychological, and social variables as risk factors potentially influencing the onset or aggravation of perinatal maternal conditions. The current pandemic emergency and the restrictive measures adopted by local governments to prevent the spread of the coronavirus infection may negatively affect mothers-to-be and new mothers potentially increasing the likelihood of anxiety, depressive or post-traumatic symptoms to develop. Moreover, the forced quarantine combined with the limited access to professional or family support may increase feelings of fatigue and isolation. The present study aims to investigate women's psychological well-being during pregnancy and in the first months after childbirth, integrating the evaluation of some traditionally studied variables with the specificities of the current situation. 575 Italian women have been administered an online self-report questionnaire assessing the presence of anxiety disorders, depressive and post-traumatic symptoms as well as the expectations toward childbirth (for mothers-to-be) or the subjective experience of childbirth (for postpartum women). Findings revealed a higher percentage of women than that reported in the literature scored above the clinical cut-off both during pregnancy and postpartum on a series of measures of psychological well-being, thus demonstrating that this period was perceived as particularly challenging and stressful and had significant impact on the women's well-being. Moreover, some socio-demographic, medical, and pandemic-related variables, especially the lack of presence and support from one's partner during labor and delivery as well as in the first days postpartum was found to predict women's mental health. These findings suggest the need for developing specific interventions targeted at women who cannot benefit from the support of their partners or family.

Utilization of companionship during delivery and associated factors among women who gave birth at Arba Minch town public health facilities, southern Ethiopia

Background

Companionship during delivery is an important feature of compassionate and respectful maternity care. It has a positive impact on delivery and birth outcomes. In low resource countries like Ethiopia lack of companionship discourages women from accessing facility-based delivery care. Therefore, this study aimed to assess the utilization of companionship during delivery and associated factors.

Methods

Health facility-based cross-sectional study design was done from October to November 2019. Interviewer administered questionnaires were used to collect the data from 418 study participants. The data were entered with Epi data version 4.4 and exported to Statistical Package for Social Sciences (SPSS) version 25.0 for analysis. Binary logistic regression was done. Statistical significance was declared at P- values < 0.05 with a 95% confidence level.

Results

The finding of the study showed that only 13.8% of mothers utilize companionship during delivery. Variables such as having a desire to have companionship during delivery in the health facilities (AOR = 5.17, CI 95% 2.63, 10.16), having complication during the labor and delivery (AOR = 3.48, CI 95%, 1.81, 6.70), and being primipara (AOR = 2.05, CI 95% 1.09, 3.87) were the independent factors associated with companionship utilization.

Conclusions

The finding of the study showed that the utilization of companionship during delivery was low. Permitting women to have a companion of choice during labor and childbirth can be a cost-effective intervention to improve the quality of maternity care, facing complications during delivery, having a desire to have companionship during delivery and primiparous women were more likely to utilize companionship. To improve this low utilization of companionship institutions and care providers should provide information about companionship during antenatal care attendance. Besides, there is a need for clear guidelines to govern the practice of companions.

PRENACEL partner - use of short message service (SMS) to encourage male involvement in prenatal care: a cluster randomized trial

Background

The partner has an important role when he participates of the prenatal care as showed in the positive results relate to the mother and the child health. For this reason it is an important strategy to bring future fathers closer to health services and to improve their link with paternity.

Aim

To evaluate whether the implementation of SMS technology, through the PRENACEL program for the partner as a health education program, is a useful supplement to the standard prenatal monitoring.

Methods

A parallel cluster randomized trial was carried out, with the clusters representing primary care health units. The 20 health units with the largest number of pregnant women in 2013 were selected for the study. There was a balance of the health units according to the size of the affiliated population and the vulnerability situation and these were allocated in intervention and control health units by the randomization. The partners of the pregnant women who started prenatal care prior to the 20th week of gestation were the study population of the intervention group. The participants received periodic short text messages via mobile phone with information about the pregnancy and birth. In the control group units the partners, together with the women, received the standard prenatal care.

Results

One hundred eighty-six partners were interviewed, 62 from the PRENACEL group, 73 from the intervention group that did not opt ​​for PRENACEL and 51 from the control group. A profile with a mean age of 30 years was found and the majority of respondents (51.3%) declared themselves as brown race/color. The interviewees presented a mean of 9.3 years of study. The majority of the men (95.2%) cohabited with their partner and 63.7% were classified as socioeconomic class C. The adherence to the PRENACEL program was 53.4%. In relation to the individual results, there was a greater participation of the PRENACEL partners in the prenatal consultations, as well as a greater presence of them accompanying the woman at the moment of the childbirth when compared to the other groups.

Conclusion

The study showed that a health education strategy using communication technology seems to be a useful prenatal care supplement; the intervention had a good acceptability and has a promising role in men’s involvement in prenatal, labour and postpartum care of their partners.

Trial registration

Clinical trial registry: RBR-54zf73, U1111–1163-7761.

The Trend of Labor Analgesia in the World and China: A Bibliometric Analysis of Publications in Recent 30 Years

Purpose

Labor analgesia is part of the most important tasks an anesthesiologist needs to deal with. With the “two-child policy” in China, the number of parturients has increased significantly, labor analgesia more should be valued. There has been a tremendous change on labor analgesia research in China and around the world; however, broader trends in the prevalence and scope of labor analgesia research remain underexplored. The current study quantitatively analyzes trends in labor analgesia research publications in the past 30 years.

Methods

A bibliometric approach was used to search Scopus, PubMed, Web of Science and the China National Knowledge Infrastructure for all labor analgesia-related research articles. The research progress and growing trend were quantitatively analyzed by total publications, research types, research institutions, journal impact factors, and author’s contribution. Total citations frequency, average citations per item and h-index were used for evaluating literature quantity.

Results

From 1988 to 2018, over 8000 documents in labor analgesia research field were published worldwide. According to Scopus, 68.2% papers of all documents were articles. The USA published the largest number of articles (2204, 27.45%). China had published 175 articles (2.18%), ranking the 11th. According to WOS, there were 221 research categories for labor analgesia articles all over the world. The total citations were 76,207, average 9.086 citations per item, and the h-index was 114, average 14 citations per item worldwide. The total citations and h-index of papers published in China were as follows: 353 total citations, 7.06 citations per item, and 10 h-index. High contribution journals, authors, institutions and the top 10 most cited articles on labor analgesia in the world and China were also listed.

Conclusion

Labor analgesia research has grown markedly during the 1988–2018 period. Although China had made remarkable achievements, there was a gap in the high-quality studies between China and other leading countries.

The childbirth experience: obstetric and psychological predictors in Italian primiparous women

BACKGROUND

The experience of childbirth crucially impacts a mother's psychological well-being and the mother-infant relationship. It is recognised that negative births can be linked to different forms of discomfort, both for the mother as well as for the infant. This prospective longitudinal study aimed to study the effect of obstetric and psychological variables on women's subjective experience of childbirth.

METHODS

111 primiparous Italian women completed a set of questionnaires at 38-40 weeks of pregnancy (Time 1) and 1-5 days after childbirth (Time 2). Sociodemographic and obstetric information were collected. Data about the childbirth were obtained from the mother's ward birth records. Women completed the Wijma Delivery Expectancy/Experience Questionnaire both before and after childbirth.

RESULTS

The subjective experience of birth was significantly predicted by the duration of the expulsive phase (β = .26; p < .05), the use of epidural analgesia (β = .21;  p< .05) and by fear of birth (β = .21; p < .05). The effect of mode of birth and duration of the dilatation phase on women's birth experience was not found.

CONCLUSIONS

In our study, neither instrumental childbirth nor caesarean section have a significant effect on women's birth experience. Instead, both a longer expulsion phase and epidural analgesia contribute to the negative experience. Moreover, the higher the fear of birth, the worse the women's emotional experience. These findings confirmed the role of obstetric and psychological variables on birth experience. More investigation about this topic could be useful to develop specific interventions to prepare women for birth.

Mothers' satisfaction with care during facility-based childbirth: a cross-sectional survey in southern Mozambique

Background

Client satisfaction is an essential component of quality of care. Health system factors, processes of care as well as mothers’ characteristics influence the extent to which care meets the expectations of mothers and families. In our study, we specifically aimed to address the mothers’ experiences of, and satisfaction with, care during childbirth.

Methods

A population-based cross-sectional study, using structured interviews with published sequences of questions assessing satisfaction, including 4358 mothers who gave birth during the 12 months before June 2016 to estimate satisfaction with childbirth care. Regression analysis was used to determine the predictors of client satisfaction.

Results

Most mothers (92.5%) reported being satisfied with care during childbirth and would recommend that a family member to deliver at the same facility. Specifically, 94.7% were satisfied with the cleanliness of the facility, 92.0% reported being satisfied with the interaction with the healthcare providers, but only 49.8% felt satisfied with the assistance to feed their baby. Mothers who had negative experiences during the process of care, such as being abandoned when needing help, disrespect, humiliation, or physical abuse, reported low levels of satisfaction when compared to those who had not had such experiences (68.5% vs 93.5%). Additionally, they reported higher levels of dissatisfaction (20.1% vs 2.1%). Regression analysis revealed that mothers who gave birth in primary level facilities tended to be more satisfied than those who gave birth in hospitals, and having a companion increased, on average, the overall satisfaction score, with 0.06 in type II health centres (CI 0.03–0.10) and with 0.05 in type I health centres (CI − 0.02 – 0.13), compared to − 0.01(CI -0.08 – 0.07) in the hospitals, irrespective of age, education and socio-economic background.

Conclusion

Childbirth at the primary level facilities contributes to the level of satisfaction. The provision of childbirth care should consider women’s preferences and needs, including having a companion of choice. We highlight the challenge in balancing safety of care versus satisfaction with care and in developing policies on the optimum configuration of childbirth care. Interventions to improve the interaction with providers and the provision of respectful care are recommended.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2449-6) contains supplementary material, which is available to authorized users.

Hypnotherapy in management of delivery pain: a review

Hypnosis in obstetrics is available for more than one hundred years, but the development of inhalational anesthetic and chemotherapy agents and anesthesia drugs pending the 19th century induced the decrement of its application. However, experimental assessment of this type of intervention on labor and delivery in not high yet. For this reason, evaluation of hypnotic techniques in preparing childbirth should be carried out. One of the main unified mind-body healing practices, which has a great remedial potential in different applications of health care like labor and delivery. Assessment of effectiveness of this procedure in various administered trials is not easy, due to methodologic challenges, like normalizing trial conditions and picking up sufficient sizes of sample. Applying techniques of hypnosis for childbirth within hospital settings makes women to easily overcome barriers associated with institutional policies or caregiver resistance. Potential analgesic and anxiolytic clinical hypnosis effects for childbirth deserve more clinical trials. In this regard, nurses who manage women pending labor and delivery could easily enhance their skills and related understandings for contributing to techniques of hypnotherapy.

Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study

Background

Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities.

Results

This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time.

Conclusions

Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

The association between childbirth experience and mother's parenting stress: The mediating role of anxiety and depressive symptoms

Childbirth is one of the most significant experiences in women's lives. A bad experience could lead to psychological distress, including severe disease. This experience has a significant impact not only on the mother's well-being, but also on her first interactions with the baby. The present study thus had two aims: 1) investigate the association between the childbirth experience and parenting stress; and 2) analyze if this relation can be mediated by the woman's psychological well-being (anxiety and depressive symptoms). One hundred fifty-eight Italian primiparous women, with a single pregnancy, recruited between January 2016 and December 2016, completed three months after delivery the following scales: Wijma Delivery Experience Questionnaire; State-Trait Anxiety Inventory; Edinburgh Postnatal Depression Scale and Parenting Stress Index (Short Form). Data were analyzed through path analyses. Results revealed that the birth experience was not directly associated with parenting stress. The final model confirmed that the childbirth experience was related to parenting stress through the full mediation of anxiety and depressive symptoms. These findings highlight the importance of making mothers' childbirth experience as positive as possible, considering the crucial impact of this experience not only on their global functioning but also on their first relationships with the baby.

Effect of a Supportive Communication Educational Program on Women's Satisfaction With Childbirth Experiences in Local Safe Delivery Posts in Iran

PURPOSE

To investigate the effect of a supportive communication educational program on satisfaction with childbirth experiences among the women giving birth in the local safe delivery posts (SDPs).

METHODS

This quasi-experimental study was conducted during September 23, 2017 and December 22, 2017. In the first phase, seven midwives were subjected to a supportive communication training program in one of two unique local SDPs in Zahedan, Iran. In the second phase, 300 women who gave birth at the SDPs (150 cases in each SDP) were entered into the study. The data were collected using the Mackey Childbirth Satisfaction Rating Scale (MCSRS).

RESULTS

The intervention group had a higher mean childbirth satisfaction score in all five subdomains, compared to the control group. However, this difference was statistically significant only in the “general” (p < .001) and “self” (p = .003) subdomains of the MCSRS. The regression model showed if the women's labor experience was just like the way they expected, they were 5.99 times more likely to be satisfied with childbirth care in SDPs.

CONCLUSION

As the findings indicated, this program made childbirth care experiences more satisfactory for disadvantaged women.

Who may accompany the parturient to the delivery room?

OBJECTIVE

To assess the association of the attendant of the parturient (husband or mother or both), on labor duration, mode of delivery, maternal and neonatal complications.

STUDY DESIGN

A retrospective cohort study, over a 4-year period, of women admitted to the delivery room accompanied by their husband, their mother or both. Medical records were reviewed for demographic, medical and obstetrical history.

RESULTS

Overall, 3029 patients were included, 2192 were accompanied by their husband; 127 were accompanied by their mother and 710 were accompanied by both. Women accompanied by their husbands were significantly older and more likely to be multiparous than women accompanied by their mother (30.2 years vs. 27.8 years, P < 0.001 and 60% vs. 48.8%, P = 0.02, respectively). Compared to women supported during labor by their mothers, women supported only by their husbands spent less hours in the delivery room (from admission to delivery) (11.1 h vs. 13.7 h, P = 0.02). While the nature of the attendant had no influence on the mode of delivery among nulliparous women (p = 0.13), multiparous women supported by the mothers had a significantly higher rate of cesarean delivery compared to those supported only by their husband or by both (OR = 2.07, 95% CI = [1.317-3.246], P = 0.002, OR = 3.33, 95% CI = [1.623-6.849],  P = 0.001, respectively).

CONCLUSIONS

Women supported by their mothers during labor have a longer second stage of labor, a decreased rate of vaginal delivery and an increased risk for cesarean delivery compared to women supported by their husbands. Future large prospective studies are needed to confirm our observation and to find causative affect.

Socio-cultural Beliefs and Practices Influencing Institutional Delivery Service Utilization in Three Communities of Ethiopia: A Qualitative Study

BACKGROUND

The influence of socio-cultural factors on institutional birth is not sufficiently documented in Ethiopia. Thus, this study explores socio-cultural beliefs and practices during childbirth and its influences on the utilization of institutional delivery services.

METHODS

A qualitative study was conducted in three regions of Ethiopia through eight focus group discussions (with women) and thirty in-depth interviews with key informants which included health workers, community volunteers, and leaders. The data were analyzed thematically.

RESULTS

The study identified six overarching socio-cultural factors influencing institutional birth in the study communities. The high preference for traditional birth attendants (TBAs) and home as it is intergenerational culture and suitable for privacy are among the factors. Correspondingly, culturally unacceptable birth practices at health facilities (such as birth position, physical assessment, delivery coach) and inconvenience of health facility setting to practice traditional birth rituals such as newborn welcoming ceremony made women avoid health facility birth. On the other hand, misperceptions and worries on medical interventions such as episiotomy, combined with mistreatment from health workers, and lack of parent engagement in delivery process discouraged women from seeking institutional birth. The provision of delivery service by male health workers was cited as a social taboo and against communities' belief system which prohibited women from giving birth at a health facility.

CONCLUSIONS

Multiple socio-cultural factors and perceptions were generally affected utilization of institutional birth in study communities. Hence, culturally competent interventions through education, re-orientation, and adaptation of beneficial norms combined with women friendly care are essential to promote health facility birth.

Effect of birth plans on childbirth experience: A systematic review

AIM

The birth plans were developed as an approach for pregnant women to present their expectations for labour and childbirth. The aim of this study was to assess whether birth plans (a written document in which pregnant women describe preferences about their care during labour and childbearing) compared with standard or routine approach (supine position, continuous fetal monitoring, enema, episiotomy) affect the birth experience (woman's perception of labour and childbirth as positive or negative experience) or satisfaction with birth.

METHODS

This systematic review was performed by searching several databases, including Cochrane Library, Web of Science, MEDLINE, Embase, CINAHL, Scopus, PsycINFO, ACP Journal Club, Google Scholar, and Persian databases (SID, Magiran, and Barakat) up to February 10, 2018.

RESULTS

By searching the databases, 1006 published articles were found, of which 480 and 114 articles were excluded by review of the titles and the abstracts, respectively. Finally, we included three clinical trials (1132 women) in the review. The results of two study showed that the mean score of birth experience in the birth plan group was significantly higher than the control group (P ≤ 0.01). However, the results of a study showed that there were no statistically significant differences between birth plan and control groups (P > 0.05). Quality of included studies was very low.

CONCLUSIONS

There is not enough evidence to support or refute that birth plan can improve the birth experience or satisfaction with birth.

Attitudes and barriers toward the presence of husbands with their wives in the delivery room during childbirth in Riyadh, Saudi Arabia

Objectives:

The objective of the study is to assess the husbands’ attitudes toward their presence with their wives during childbirth in the delivery room and to determine the barriers that prevent their presence.

Methods:

A cross-sectional study was conducted at two tertiary hospitals in Riyadh. Data were collected from a total of 250 husbands whom were selected randomly in the waiting areas of the delivery rooms and asked to participate in this study by filling a questionnaire after giving informed consent; data were collected during the period between December 2016 and April 2017.

Results:

The majority (95.6%) were Saudi and had only one wife. The positive mean score for the attitude increased significantly with increasing educational level (P < 0.01). The highest positive attitude was mainly for the item “It is calming for the mother.” Conversely, the highest negatively scored item was “my presence with my wife in the delivery room is insulting to my manhood” and “our culture is against a husband attending his wife's childbirth” (1.91 ± 1.12). The hospital system and not having a private room for their wives were the most identified barriers to the husband's presence in the delivery room.

Conclusions:

Increased level of education has better outcomes on husbands’ attitudes toward supporting their wives in the delivery room. Authors recommend flexible hospital policies to support husbands’ presences with their wives in the delivery room and provide privacy for them during childbirth, such will provide psychosocial support to the wife, and it is an important part in transition to a mother-friendly hospitals.

"We need good nutrition but we have no money to buy food": sociocultural context, care experiences, and newborn health in two UNHCR-supported camps in South Sudan

BACKGROUND

Determinants of newborn health and survival exist across the reproductive life cycle, with many sociocultural and contextual factors influencing outcomes beyond the availability of, and access to, quality health services. In order to better understand key needs and opportunities to improve newborn health in refugee camp settings, we conducted a multi-methods qualitative study of the status of maternal and newborn health in refugee camps in Upper Nile state, South Sudan.

METHODS

In 2016, we conducted 18 key informant interviews with health service managers and front-line providers and 13 focus group discussions in two Sudanese refugee camps in Maban County, South Sudan. Our focus group discussions comprised 147 refugee participants including groups of mothers, fathers, grandmothers, traditional birth attendants, community health workers, and midwives. We analysed our data for content and themes using inductive and deductive techniques.

RESULTS

We found both positive practices and barriers to newborn health in the camps throughout the reproductive lifecycle. Environmental and contextual factors such as poor nutrition, lack of livelihood opportunities, and insecurity presented barriers to both general health and self-care during pregnancy. We found that the receipt of material incentives is one of the leading drivers of utilization of antenatal care and facility-based childbirth services. Barriers to facility-based childbirth included poor transportation specifically during the night; insecurity; being accustomed to home delivery; and fears of an unfamiliar birth environment, caesarean section, and encountering male health care providers during childbirth. Use of potentially harmful traditional practices with the newborn are commonplace including mixed feeding, use of herbal infusions to treat newborn illnesses, and the application of ash and oil to the newborn's umbilicus.

CONCLUSIONS

Numerous sociocultural and contextual factors impact newborn health in this setting. Improving nutritional support during pregnancy, strengthening community-based transportation for women in labour, allowing a birth companion to be present during delivery, addressing harmful home-based newborn care practices such as mixed feeding and application of foreign substances to the umbilicus, and optimizing the networks of community health workers and traditional birth attendants are potential ways to improve newborn health outcomes.

First do no harm - interventions during labor and maternal satisfaction: a descriptive cross-sectional study

BACKGROUND

Interventions can be lifesaving when properly implemented but can also put the lives of both mother and child at risk by disrupting normal physiological childbirth when used indiscriminately without indications. Therefore, this study was performed to investigate the effect of frequent interventions during labor on maternal satisfaction and to provide evidence-based recommendations for labor management decisions.

METHODS

The study was performed in descriptive design in a state hospital in Kars, Turkey with 351 pregnant women who were recruited from the delivery ward. The data were collected using three questionnaires: a survey form containing sociodemographic and obstetric characteristics, the Scale for Measuring Maternal Satisfaction in Vaginal Birth, and an intervention observation form.

RESULTS

The average satisfaction scores of the mothers giving birth in our study were found to be low, at 139.59 ± 29.02 (≥150.5 = high satisfaction level, < 150.5 = low satisfaction level). The percentages of the interventions that were carried out were as follows: 80.6%, enema; 22.2%, perineal shaving; 70.7%, induction; 95.4%, continuous EFM; 92.3%, listening to fetal heart sounds; 72.9%, vaginal examination (two-hourly); 31.9%, amniotomy; 31.3%, medication for pain control; 74.9%, intravenous fluids; 80.3%, restricting food/liquid intake; 54.7%, palpation of contractions on the fundus; 35.0%, restriction of movement; 99.1%, vaginal irrigation with chlorhexidine; 85.5%, using a "hands on" method; 68.9%, episiotomy; 74.6%, closed glottis pushing; 43.3%, fundal pressure; 55.3%, delayed umbilical cord clamping; 86.0%, delayed skin-to-skin contact; 60.1%, controlled cord traction; 68.9%, postpartum hemorrhage control; and 27.6%, uterine massage. The satisfaction levels of those who experienced the interventions of induction, EFM, restriction of movement, two-hourly vaginal examinations, intravenous fluid, fundal pressure, episiotomy, palpation of contractions on the fundus, closed glottis pushing, delayed umbilical cord clamping, delayed skin-to-skin contact, fluid/food restriction, and of those who were not provided pharmacological pain control were found to be lower (p < 0.05).

CONCLUSION

Medical interventions carried out at high rates had a negative impact on women's childbirth experience. Therefore, a proper assessment in the light of medical evidence should be made before deciding that it is absolutely necessary to intervene in the birthing process and the interdisciplinary team should ensure that intrapartum caregivers will "first do no harm."

Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India

Background

Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities.

Methods

This paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women’s experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities.

Results

The exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust.

Conclusions

The results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices.

Pharmacological pain relief and fear of childbirth in low risk women; secondary analysis of the RAVEL study

BACKGROUND

Fear of childbirth may reduce the womens' pain tolerance during labour and may have impact on the mother-infant interaction. We aimed to assess (1) the association between fear of childbirth antepartum and subsequent request for pharmacological pain relief, and (2) the association between the used method of pain relief and experienced fear of childbirth as reported postpartum in low risk labouring women.

METHODS

Secondary analysis of the RAVEL study, a randomised controlled trial comparing remifentanil patient controlled analgesia (PCA) and epidural analgesia to relieve labour pain. The RAVEL study included 409 pregnant women at low risk for obstetric complications at 18 midwifery practices and six hospitals in The Netherlands (NTR 3687). We measured fear of childbirth antepartum and experienced fear of childbirth reported postpartum, using the Wijma Delivery Expectancy/Experience Questionnaire.

RESULTS

Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association did not reach statistical significance (adjusted odds ratio (aOR2.0; 95% confidence interval (CI) 0.8-4.6). Women who received epidural analgesia more frequently reported fear of childbirth postpartum compared to women who did not receive epidural analgesia (aOR3.5; CI 1.5-8.2), while the association between remifentanil-PCA and fear of childbirth postpartum was not statistically significant (aOR1.7; CI 0.7-4.3).

CONCLUSIONS

Women with fear of childbirth antepartum more frequently requested pain relief compared to women without fear of childbirth antepartum, but this association was not statistically significant. Women who received pharmacological pain relief more frequently reported that they had experienced fear of childbirth during labour compared to women who did not receive pain relief. Based on our data epidural analgesia with continuous infusion does not seem to be preferable over remifentanil-PCA as method of pain relief when considering fear of childbirth postpartum.

TRIAL REGISTRATION

Netherlands Trial Register 3687 ; Register date: 5 Nov 2012.

Complementary medicine for laboring women: a qualitative study of the effects of reflexology

Background

Despite pharmacological interventions, labor pain and anxiety still remain a challenge, and can carry long-term psychological complications. The goal of this study was to assess the effect of reflexology on these symptoms and to explore the physical and psychological components of women’s experience associated with this treatment.

Methods

This qualitative study was conducted in an Israeli university hospital that offers integrative medicine services. Reflexology was offered to laboring women in the hospital, by the medical staff. In-depth, open interviews were conducted with 36 women, still in hospital, who consented to be interviewed, within 48 h after delivery. Questions referred to their labor experience with reflexology treatment.

Results

Of the 36 participants, 34 (94%) described a positive and empowering experience. They reported reduced pain and anxiety, and an increased sense of self-efficacy brought about by the ability to become active and manage labor.

Conclusions

Using reflexology as one of the complementary medicine treatment available can contribute greatly to the entire labor experience as it empowers women and increases self-confidence and ability to self-manage labor and delivery.

"Five hundred years of medicine gone to waste"? Negotiating the implementation of an intercultural health policy in the Ecuadorian Andes

BACKGROUND

In Ecuador, indigenous women have poorer maternal health outcomes and access to maternity services. This is partly due to cultural barriers. A hospital in Ecuador implemented the Vertical Birth (VB) policy to address such inequities by adapting services to the local culture. This included conducting upright deliveries, introducing Traditional Birth Attendants (TBAs) and making physical adaptations to hospital facilities.

METHODS

Using qualitative methods, we studied the VB policy implementation in an Ecuadorian hospital to analyse the factors that affect effective implementation of intercultural health policies at the local level. We collected data through observation, in-depth interviews, a focus group discussion, and documentation review. We conducted 46 interviews with healthcare workers, managers, TBAs, key informants and policy-makers involved in maternal health. Data analysis was guided by grounded theory and drew heavily on concepts of "street-level bureaucracy" to interpret policy implementation.

RESULTS

The VB policy was highly controversial; actors' values (including concerns over patient safety) motivated their support or opposition to the Vertical Birth policy. For those who supported the policy, managers, policy-makers, indigenous actors and a minority of healthcare workers supported the policy, it was critical to address ethnic discrimination to improve indigenous women's access to the health service. Most healthcare workers initially resisted the policy because they believed vertical births led to poorer clinical outcomes and because they resented working alongside TBAs. Healthcare workers developed coping strategies and effectively modified the policy. Managers accepted these as a compromise to enable implementation.

CONCLUSIONS

Although contentious, intercultural health policies such as the VB policy have the potential to improve maternity services and access for indigenous women. Evidence-base medicine should be used as a lever to facilitate the dialogue between healthcare workers and TBAs and to promote best practice and patient safety. Actors' values influenced policy implementation; policy implementation resulted from an ongoing negotiation between healthcare workers and managers.

Regional variations in childbirth interventions in the Netherlands: a nationwide explorative study

BACKGROUND

Although interventions in childbirth are important in order to prevent neonatal and maternal morbidity and mortality, non-indicated use may cause avoidable harm. Regional variations in intervention rates, which cannot be explained by maternal characteristics, may indicate over- and underuse. The aim of this study is to explore regional variations in childbirth interventions in the Netherlands and their associations with interventions and adverse outcomes, controlled for maternal characteristics.

METHODS

Childbirth intervention rates were compared between twelve Dutch regions, using data from the national perinatal birth register for 2010-2013. All single childbirths from 37 weeks' gestation onwards were included. Primary outcomes were induction and augmentation of labour, pain medication, instrumental birth, caesarean section (prelabour, intrapartum) and paediatric involvement. Secondary outcomes were adverse neonatal and maternal outcomes. Multivariable logistic regression analyses were used to adjust for maternal characteristics. Associations were expressed in Spearman's rank correlation coefficients.

RESULTS

Most variation was found for type of pain medication and paediatric involvement. Epidural analgesia rates varied from between 12 and 38% (nulliparous) and from between 5 and 14% (multiparous women). These rates were negatively correlated with rates of other pharmacological pain relief, which varied from between 15 and 43% (nulliparous) and from between 10 and 27% (multiparous). Rates of paediatric involvement varied from between 37 and 60% (nulliparous) and from between 26 and 43% (multiparous). For instrumental vaginal births, rates varied from between 16 and 19% (nulliparous) and from between 3 and 4% (multiparous). For intrapartum caesarean section, the variation was 13-15% and 5-6%, respectively. A positive correlation was found between intervention rates in midwife-led and obstetrician-led care at the onset of labour within the same region. Adverse neonatal and maternal outcomes were not lower in regions with higher intervention rates. Higher augmentation of labour rates correlated with higher rates of severe postpartum haemorrhage.

CONCLUSIONS

Most variation was found for type of pain medication and paediatric involvement, and least for instrumental vaginal births and intrapartum caesarean sections. Care providers and policy makers should critically audit remarkable variations, since these may be unwarranted. Limited variation for some interventions may indicate consensus for their use. Further research should focus on variations in evidence-based interventions and indications for the use of interventions in childbirth.

Clinical nursing and midwifery research in Latin American and Caribbean countries: A scoping review

AIM

To identify and describe published, nursing-led and midwifery-led, clinical research that has been conducted in Latin America and the Caribbean.

BACKGROUND

Peer-reviewed published research may correspond to and elucidate country's realities, priorities, and needs.

DESIGN

A 6-stage scoping review methodology was used to search scientific databases using an applied search strategy.

DATA SOURCES

Five databases were searched for articles published in English, Spanish, or Portuguese conducted in a Latin American or Caribbean country between January 1, 2006 and June 14, 2016.

REVIEW METHODS

Articles were independently considered for inclusion by 2 researchers, data extracted, and study characteristics described.

RESULTS

Of 6922 articles identified, 404 were included. The majority were conducted in Brazil (90.6%) followed by Chile (2.5%). Most were nurse-led (95.8%) and were implemented in hospitals (48.6%). Studies frequently explored patient knowledge or characterized patient populations (61.3%) and commonly assessed chronic disease (19.3%) or maternity/child health outcomes (15.9%).

CONCLUSION

Findings revealed a large number of publications but an uneven geographical distribution of nurse-led clinical research and an evident gap of midwifery-related research in Latin America and the Caribbean. Results may be used to build research agendas to promote nursing and midwifery research capacity and further establish evidence-based practice.

Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial

BACKGROUND

Newborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes.

METHODS

From 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1-6 and 7-12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later.

RESULTS

Adjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32-0·51; p < 0.001) in months 1-6 and 0·30 (95% CI 0·21-0·43; p < 0·001) in months 7-12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53-0·77; p < 0·001) in months 1-6 and 0·48 (95% CI 0·36-0·63; p < 0·001) in months 7-12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25-32; p < 0·001) and 31% (95% CI 27-36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively.

CONCLUSIONS

This training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs.

TRIAL REGISTRATION

Retrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924 .

Quality of care during childbirth in Tanzania: identification of areas that need improvement

BACKGROUND

Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania.

METHODS

The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the 'stages of labour'. Themes were identified through identification of recurrent patterns.

RESULTS

Three themes were identified: 1) Women's movement between rooms during birth, 2) health providers' assumptions and hope for a 'normal' birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers 'assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene.

CONCLUSIONS

Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.

Care quality following intrauterine death in Spanish hospitals: results from an online survey

BACKGROUND

The objective of the study was to evaluate practices in Spanish hospitals after intrauterine death in terms of medical/ technical care and bereavement support care.

METHODS

A cross-sectional descriptive study using an online self-completion questionnaire. The population was defined as women who had experienced an intrauterine fetal death between sixteen weeks and birth, either through spontaneous late miscarriage/stillbirth or termination of pregnancy for medical reasons. Respondents were recruited through an online advertisement on a stillbirth charity website and social media. The analysis used Pearson's chi-squared (p ≤ 0.05) test of independence to cross-analyse for associations between objective measures of care quality and independent variables.

RESULTS

Responses from 796 women were analysed. Half of the women (52.9%) had postmortem contact with their baby. 30.4% left the hospital with a least one linking object or a photograph. In 35.8% of cases parents weren't given any option to recover the body/remains. 22.9% of births ≥26 weeks gestation were by caesarean, with a significant (p < 0.001) difference between public hospitals (16.8%) and private hospitals (41.5%). 29.3% of respondents were not accompanied during the delivery. 48.0% of respondents recalled being administered sedatives at least once during the hospital stay. The autopsy rate in stillbirth cases (≥ 20 weeks) was 70.5% and 44.4% in cases of termination of pregnancy (all gestational ages). Consistent significant (p < 0.05) differences in care practices were found based on gestational age and type of hospital (public or private), but not to other variables related to socio-demographics, pregnancy history or details of the loss/death. Intrauterine deaths at earlier gestational ages received poorer quality care.

CONCLUSIONS

Supportive healthcare following intrauterine death is important to women's experiences in the hospital and beneficial to the grief process. Many care practices that are standard in other high-income countries are not routine in Spanish hospitals. Providing such care is a relatively new phenomenon in the Spanish health system, the results provide a quality benchmark and identify a number of areas where hospitals could make improvements to care practices that should have important psychosocial benefits for women and their families.

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status

OBJECTIVES

Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status.

METHODS

Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms.

RESULTS

Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured.

CONCLUSIONS

There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.

Psychosocial factors and their influence on the experience of pain

Over the past 20 years, our understanding of social factors on pain experience has increased. Edwards et al observed that the presence of a friend resulted in an increased pain threshold and tolerance to experimentally induced pain (cold pressor test and pressure algometry). Having a male friend present had the most prominent effect on male participants' reporting of pain. However, the effects of psychosocial traits known to effect pain experience (eg, catastrophising) were not considered.

Continuous support for women during childbirth

BACKGROUND

Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine.

OBJECTIVES

The primary objective was to assess the effects, on women and their babies, of continuous, one-to-one intrapartum support compared with usual care, in any setting. Secondary objectives were to determine whether the effects of continuous support are influenced by:1. Routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour, including: policies about the presence of support people of the woman's own choosing; epidural analgesia; and continuous electronic fetal monitoring.2. The provider's relationship to the woman and to the facility: staff member of the facility (and thus has additional loyalties or responsibilities); not a staff member and not part of the woman's social network (present solely for the purpose of providing continuous support, e.g. a doula); or a person chosen by the woman from family members and friends;3. Timing of onset (early or later in labour);4. Model of support (support provided only around the time of childbirth or extended to include support during the antenatal and postpartum periods);5. Country income level (high-income compared to low- and middle-income).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 June 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care. Quasi-randomised and cross-over designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We sought additional information from the trial authors. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included a total of 27 trials, and 26 trials involving 15,858 women provided usable outcome data for analysis. These trials were conducted in 17 different countries: 13 trials were conducted in high-income settings; 13 trials in middle-income settings; and no studies in low-income settings. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (average RR 1.08, 95% confidence interval (CI) 1.04 to 1.12; 21 trials, 14,369 women; low-quality evidence) and less likely to report negative ratings of or feelings about their childbirth experience (average RR 0.69, 95% CI 0.59 to 0.79; 11 trials, 11,133 women; low-quality evidence) and to use any intrapartum analgesia (average RR 0.90, 95% CI 0.84 to 0.96; 15 trials, 12,433 women). In addition, their labours were shorter (MD -0.69 hours, 95% CI -1.04 to -0.34; 13 trials, 5429 women; low-quality evidence), they were less likely to have a caesarean birth (average RR 0.75, 95% CI 0.64 to 0.88; 24 trials, 15,347 women; low-quality evidence) or instrumental vaginal birth (RR 0.90, 95% CI 0.85 to 0.96; 19 trials, 14,118 women), regional analgesia (average RR 0.93, 95% CI 0.88 to 0.99; 9 trials, 11,444 women), or a baby with a low five-minute Apgar score (RR 0.62, 95% CI 0.46 to 0.85; 14 trials, 12,615 women). Data from two trials for postpartum depression were not combined due to differences in women, hospitals and care providers included; both trials found fewer women developed depressive symptomatology if they had been supported in birth, although this may have been a chance result in one of the studies (low-quality evidence). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, such as admission to special care nursery (average RR 0.97, 95% CI 0.76 to 1.25; 7 trials, 8897 women; low-quality evidence), and exclusive or any breastfeeding at any time point (average RR 1.05, 95% CI 0.96 to 1.16; 4 trials, 5584 women; low-quality evidence).Subgroup analyses suggested that continuous support was most effective at reducing caesarean birth, when the provider was present in a doula role, and in settings in which epidural analgesia was not routinely available. Continuous labour support in settings where women were not permitted to have companions of their choosing with them in labour, was associated with greater likelihood of spontaneous vaginal birth and lower likelihood of a caesarean birth. Subgroup analysis of trials conducted in high-income compared with trials in middle-income countries suggests that continuous labour support offers similar benefits to women and babies for most outcomes, with the exception of caesarean birth, where studies from middle-income countries showed a larger reduction in caesarean birth. No conclusions could be drawn about low-income settings, electronic fetal monitoring, the timing of onset of continuous support or model of support.Risk of bias varied in included studies: no study clearly blinded women and personnel; only one study sufficiently blinded outcome assessors. All other domains were of varying degrees of risk of bias. The quality of evidence was downgraded for lack of blinding in studies and other limitations in study designs, inconsistency, or imprecision of effect estimates.

AUTHORS' CONCLUSIONS

Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support. Subgroup analyses should be interpreted with caution, and considered as exploratory and hypothesis-generating, but evidence suggests continuous support with certain provider characteristics, in settings where epidural analgesia was not routinely available, in settings where women were not permitted to have companions of their choosing in labour, and in middle-income country settings, may have a favourable impact on outcomes such as caesarean birth. Future research on continuous support during labour could focus on longer-term outcomes (breastfeeding, mother-infant interactions, postpartum depression, self-esteem, difficulty mothering) and include more woman-centred outcomes in low-income settings.

Effects of auriculotherapy on labour pain: a randomized clinical trial

OBJECTIVE

Assessing the effects of auriculotherapy in pain control and its outcomes on the duration of labour.

METHOD

This is a randomized, controlled, double-blind trial with preliminary data. Thirty pregnant women with gestational age ≥ 37 weeks, cervical dilatation ≥ 4 cm and two or more contractions in 10 minutes were selected and randomly divided into three groups: auriculotherapy, placebo and control. Auriculotherapy was applied using crystal beads on four strategic points.

RESULTS

No statistical significance was found between the groups with regard to pain; however, the women from the auriculotherapy group had lower intensity and less perception of pain at 30, 60 and 120 minutes of treatment. The average duration of labour was shorter in the auriculotherapy group (248.7 versus placebo 414.8 versus control 296.3 minutes); caesarean section rates were higher in the placebo group (50%) and the same in the other groups (10%).

CONCLUSION

Mothers who received auriculotherapy presented a tendency for greater pain control and shorter labour duration; however, caesarean section rates in this group were similar to the control group. This trial precedes a larger study in progress. Registration of Brazilian Clinical Trials: RBR-47hhbj.

OBJETIVO

Avaliar os efeitos da auriculoterapia no controle da dor e seus desfechos na duração do trabalho de parto.

MÉTODO

Trata-se de um ensaio controlado, randomizado e duplo-cego, com dados preliminares. Foram selecionadas 30 parturientes com idade gestacional ≥ 37 semanas, dilatação cervical ≥ 4 cm e duas ou mais contrações em 10 minutos, divididas aleatoriamente em três grupos: auriculoterapia, placebo ou controle. A auriculoterapia foi aplicada com microesferas de cristais em quatro pontos estratégicos.

RESULTADOS

Não houve significância estatística entre os grupos com relação à dor; no entanto, as mulheres do grupo de auriculoterapia, apresentaram menor intensidade e menor percepção da dor aos 30, 60 e 120 minutos do tratamento. A média de duração do trabalho de parto foi menor no grupo de auriculoterapia (248,7 versus placebo 414,8 versus controle 296,3 minutos); a taxa de cesárea foi maior no grupo placebo (50%) e igual nos outros (10%).

CONCLUSÃO

As parturientes que receberam auriculoterapia apresentaram tendência a um maior controle da dor e menor duração do trabalho de parto, porém a taxa de cesárea neste grupo foi semelhante à do grupo controle. Este ensaio precede um estudo maior, em andamento. Registro Brasileiro de Ensaio Clínico: RBR-47hhbj.

Cost-effectiveness of the Yashoda Programme

Background:

Under the Norway-India Partnership Initiative (NIPI), a pilot programme was launched in 2008 to improve the quality of institutional maternal and neonatal care through Yashodas or birth companions. Yashodas were placed at higher-level healthcare facilities across select districts of India to support mother and newborn. This article presents the additional cost of the Yashoda programme from a government perspective and models the potential cost-effectiveness of the Yashoda intervention in averting neonatal deaths.

Methods:

We estimated the additional costs of the Yashoda programme (2011–2012) using an activity-based costing approach from a provider perspective. Effectiveness measure was estimated as the difference in the average rate of receipt of counselling (for mothers who delivered at district hospitals) between intervention and comparison districts. The potential impact of the Yashoda programme on neonatal mortality was modelled from secondary data assuming a 30 per cent reduction in neonatal mortality among those who received counselling and practiced safe newborn care practices.

Results:

The additional cost of Yashoda intervention was US$26,350 per year or US$0.83 per live birth. Eighty-four per cent of mothers in the intervention group received essential postpartum newborn care counselling at the facility compared to 62 per cent of mothers in the comparison groups. Through potential change in newborn care practices, the Yashoda intervention was estimated to avert 45 neonatal deaths for a hypothetical cohort of 100,000 mothers who delivered at district hospitals. The incremental cost of the Yashoda intervention was US$1,832 per neonatal death averted or US$29 per life year saved (LYS). Sensitivity analysis showed the incremental cost per LYS of the Yashoda intervention varied between US$14 and US$59.

Conclusion:

This study concludes that the Yashoda intervention, when scaled up at high delivery load facilities, is a very cost-effective intervention to save newborn lives.

Exploring perceptions of instructors about childbirth preparation training courses: A qualitative study

BACKGROUND

Childbirth preparation training courses on maternal and neonatal health increase awareness, and capability of pregnant women in overcoming fear and anxiety and managing labor pains.

OBJECTIVE

To identify the affecting factors and barriers of these courses from the perspective of their instructors.

METHODS

This qualitative study of the content analysis type, has been conducted on 16 certified teachers of the training courses of the Hamadan city in 2015. Data were collected by semi-structured in-depth interviews and were then analyzed by using MAXQDA10 application.

RESULTS

Participants' experiences are indicated on three main themes including the objectives of the course, facilitators and barriers. The main objectives of the course were reported as to improve maternal and newborn health, promote natural childbirth and preparedness for parenting and breastfeeding. The main facilitators of the successful implementation include observing educational standards, strengthening the communication and relationship between mothers and staff, mobilization, and the role of instructor. The major barriers are reported as inadequate support from management system, insufficient intra-sector collaboration, poor attitude of obstetricians and physicians, inadequate access, theory-practice gap and not intended to labor naturally.

CONCLUSION

The results of our study show that multiple factors are involved in the participation of pregnant women in antenatal classes. Promoting natural childbirth requires intra-sector and inter-sectoral collaboration, as well as the community participation.

Maternity health care: The experiences of Sub-Saharan African women in Sub-Saharan Africa and Australia

BACKGROUND

Increasing global migration is resulting in a culturally diverse population in the receiving countries. In Australia, it is estimated that at least four thousand Sub-Saharan African women give birth each year. To respond appropriately to the needs of these women, it is important to understand their experiences of maternity care.

OBJECTIVE

The study aimed to examine the maternity experiences of Sub-Saharan African women who had given birth in both Sub-Saharan Africa and in Australia.

DESIGN

Using a qualitative approach, 14 semi-structured interviews with Sub-Saharan African women now living in Australia were conducted. Data was analysed using Braun and Clark's approach to thematic analysis.

FINDINGS

Four themes were identified; access to services including health education; birth environment and support; pain management; and perceptions of care. The participants experienced issues with access to maternity care whether they were located in Sub-Saharan Africa or Australia. The study draws on an existing conceptual framework on access to care to discuss the findings on how these women experienced maternity care.

CONCLUSION

The study provides an understanding of Sub-Saharan African women's experiences of maternity care across countries. The findings indicate that these women have maternity health needs shaped by their sociocultural norms and beliefs related to pregnancy and childbirth. It is therefore arguable that enhancing maternity care can be achieved by improving women's health literacy through health education, having an affordable health care system, providing respectful and high quality midwifery care, using effective communication, and showing cultural sensitivity including family support for labouring women.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system.

Advice given by community members to pregnant women: a mixed methods study

Background

Smoking and excess weight gain during pregnancy have been shown to have serious health consequences for both mothers and their infants. Advice from friends and family on these topics influences pregnant women’s behaviors. The purpose of our study was to compare the advice that community members give pregnant women about smoking versus the advice they give about pregnancy weight gain.

Methods

A survey was sent via text messaging to adults in a diverse, low-income primary care clinic in 2015. Respondents were asked what advice (if any) they have given pregnant women about smoking or gestational weight gain and their comfort-level discussing the topics. Descriptive statistics were used to characterize the sample population and to determine response rates. Open-ended responses were analyzed qualitatively using grounded theory analysis with an overall convergent parallel mixed methods design.

Results

Respondents (n = 370) were 77 % female, 40 % black, and 25 % reported education of high school or less. More respondents had spoken to pregnant women about smoking (40 %, n = 147) than weight gain (20 %, n = 73). Among individuals who had not discussed either topic (n = 181), more reported discomfort in talking about weight gain (65 %) compared to smoking (34 %; p < 0.0001). Advice about smoking during pregnancy (n = 148) was frequently negative, recommending abstinence and identifying smoking as harmful for baby and/or mother. Advice about weight gain in pregnancy (n = 74) revealed a breadth of messages, from reassurance about all weight gain (“Eat away” or “It’s ok if you are gaining weight”), to specific warnings against excess weight gain (“Too much was dangerous for her and the baby.”).

Conclusions

Many community members give advice to pregnant women. Their advice reveals varied perspectives on the effects of pregnancy weight gain. Compared to a nearly ubiquitous understanding of the harms of smoking during pregnancy, community members demonstrated less awareness of and willingness to discuss the harms of excessive weight gain. Beyond educating pregnant women, community-level interventions may also be important to ensure that the information pregnant women receive supports healthy behaviors and promotes the long-term health of both moms and babies.