Does midwifery continuity of care make a difference to women with perinatal mental health conditions: A cohort study, from Australia

Midwifery continuity of care for women with perinatal mental health conditions: A cohort study from Australia

BACKGROUND

Perinatal mental health (PMH) conditions are associated with adverse outcomes such as maternal suicide, preterm birth and longer-term childhood sequelae. Midwifery continuity of care (one midwife or a small group of midwives) has demonstrated benefits for women and newborns, including a reduction in preterm birth and improvements in maternal anxiety/worry and depression.

AIM

To determine if midwifery care provided through a Midwifery Group Caseload Practice model is associated with improved perinatal outcomes for women who have anxiety and depression and/or other perinatal mental health conditions. An EPDS ≥ 13, and/or answered the thought of harming myself has occurred to me and/or women who self-reported a history compared to standard models of care (mixed midwife/obstetric fragmented care).

METHODS

A retrospective cohort study using data routinely collected via an electronic database between 1 January 2018 31st of January 2021. The population were women with current/history of PMH, who received Midwifery Caseload Group Practice (MCP), or standard care (SC). Data were analysed using descriptive statistics for maternal characteristics and logistic regression for birth outcomes. One-to-one matching of the MCP group with the SC group was based on propensity scores.

RESULTS

7,359 births were included MCP 12% and SC 88%. Anxiety was the most common PMH with the same proportion affected in MCP and SC. Adjusted odds of preterm birth and adverse perinatal outcomes were lower in the MCP group than the SC group (aOR (95%CI): 0.77 (0.55, 1.08) and 0.81 (0.68, 0.97), respectively) and higher for vaginal birth and full breastfeeding (aOR (95% CI): 1.87 (1.60, 2.18) and 2.06 (1.61, 2.63), respectively). In the matched sample the estimate of a relationship between MCP and preterm birth (aOR (95% CI): 0.88 (0.56, 1.42), adverse perinatal outcomes (aOR (95% CI): 0.83 (0.67, 1.05)) and breastfeeding at discharge (aOR (95% CI): 1.82 (1.30, 2.51)), stronger for vaginal birth (aOR (95% CI): 2.22 (1.77, 2.71)).

CONCLUSION

This study supports positive associations between MCP and breastfeeding and vaginal birth. MCP was also associated with lower risk of adverse perinatal outcomes, though in the matched sample with a smaller sample size, the confidence interval included 1. The direction of the association MCP and preterm birth was negative (protective). However, in the matched sample analysis, the confidence interval was wide, and the finding was also consistent with no benefit from MCP. Randomised controlled trials are required to answer questions around preterm birth and adverse perinatal outcomes and further research is being planned.

Common mental disorders and perinatal outcomes in Victoria, Australia: A population-based retrospective cohort study

PURPOSE

Common mental disorders (non-psychotic mental health conditions which impact on day-to-day functioning) are increasingly common in childbearing women and may impact significantly on both maternal and neonatal outcomes. Our study examines the associations between common mental disorders and perinatal outcomes.

METHODS

We used routinely collected perinatal data (2009-2016) for this population-based retrospective cohort study (n = 597,522 singleton births). We undertook multiple logistic regression adjusting for key maternal medical conditions and sociodemographic factors to determine associations between maternal common mental disorders and adverse perinatal outcomes with confidence intervals set at 95%.

RESULTS

Women with common mental disorders were more likely to have an induction of labour and caesarean birth, have a postpartum haemorrhage (PPH), and be admitted to the Intensive Care Unit (ICU) than women without common mental disorders. Neonates of women with common mental disorders were more likely to have an Apgar score at five minutes of less than seven (a measure of neonatal wellbeing at birth), be born preterm and low birthweight, be admitted to the Special Care Nursery or Neonatal Intensive Care Unit (SCN/NICU) and have a congenital anomaly than neonates of women without common mental disorders.

CONCLUSION

Common mental disorders during the perinatal period were associated with poorer perinatal outcomes for mothers and their neonates. Strategies that enable early recognition and response to maternal common mental disorders should be developed to mitigate the consequential impact on maternal and infant wellbeing.

Obstetric and neonatal outcomes in pregnant women with and without a history of specialist mental health care: a national population-based cohort study using linked routinely collected data in England

BACKGROUND

Pregnant women with pre-existing mental illnesses have increased risks of adverse obstetric and neonatal outcomes compared with pregnant women without pre-existing mental illnesses. We aimed to estimate these differences in risks according to the highest level of pre-pregnancy specialist mental health care, defined as psychiatric hospital admission, crisis resolution team (CRT) contact, or specialist community care only, and the timing of the most recent care episode in the 7 years before pregnancy.

METHODS

Hospital and birth registration records of women with singleton births between April 1, 2014, and March 31, 2018 in England were linked to records of babies and records from specialist mental health services provided by the England National Health Service, a publicly funded health-care system. We compared the risks of adverse pregnancy outcomes, including fetal and neonatal death, preterm birth, and babies being born small for gestational age (SGA; birthweight <10th percentile), and composite indicators for neonatal adverse outcomes and maternal morbidity, between women with and without a history of contact with specialist mental health care. We calculated odds ratios adjusted for maternal characteristics (aORs), using logistic regression.

FINDINGS

Of 2 081 043 included women (mean age 30·0 years; range 18-55 years; 77·7% White, 11·4% South Asian, 4·7% Black, and 6·2% mixed or other ethnic background), 151 770 (7·3%) had at least one pre-pregnancy specialist mental health-care contact. 7247 (0·3%) had been admitted to a psychiatric hospital, 29 770 (1·4%) had CRT contact, and 114 753 (5·5%) had community care only. With a pre-pregnancy mental health-care contact, risk of stillbirth or neonatal death within 7 days of birth was not significantly increased (0·45-0·49%; aOR 1·11, 95% CI 0·99-1·24): risk of preterm birth (<37 weeks) increased (6·5-9·8%; aOR 1·53, 1·35-1·73), as did risk of SGA (6·2- 7·5%; aOR 1·34, 1·30-1·37) and neonatal adverse outcomes (6·4-8·4%; aOR 1·37, 1·21-1·55). With a pre-pregnancy mental health-care contact, risk of maternal morbidity increased slightly from 0·9% to 1·0% (aOR 1·18, 1·12-1·25). Overall, risks were highest for women who had a psychiatric hospital admission any time or a mental health-care contact in the year before pregnancy.

INTERPRETATION

Information about the level and timing of pre-pregnancy specialist mental health-care contacts helps to identify women at increased risk of adverse obstetric and neonatal outcomes. These women are most likely to benefit from dedicated community perinatal mental health teams working closely with maternity services to provide integrated care.

FUNDING

National Institute for Health Research.

Feeling anxious'- women's experiences of having a baby in Australia during the COVID-19 pandemic using the Voqual real time app

PURPOSE

Internationally, the COVID-19 pandemic impacted maternity services. In Australia, this included changes to antenatal appointments and the reduction of support people during labour and birth. For women pregnant during the pandemic there were increased stressors of infection in the community and in hospitals along with increased periods of isolation from friends and families during lockdown periods. The aim of this study was to explore the real-time experiences of women who were pregnant and had a baby during the first wave of the COVID-19 pandemic in Australia.

METHODS

This study followed seven women throughout their pregnancy and early parenthood. Women created audio or video recordings in real time using the Voqual app and were followed up by in-depth interviews after they gave birth.

RESULTS

Using narrative analysis their individual stories were compared and an overarching theme of 'feeling anxious' was found which was underpinned by the two themes 'model of care' and 'environment'.

CONCLUSIONS

These findings highlight the protective impact midwifery continuity of care has on reducing anxiety in women during the pandemic, and that the home environment can either be secure and safe or a place of isolation.

Syphilis in pregnancy: a qualitative investigation of healthcare provider perspectives on barriers to syphilis screening during pregnancy in south-east Queensland

BACKGROUND

Increasing rates of syphilis in pregnancy (SiP) in Australia and other high-income countries, has led to the resurgence of congenital syphilis. Suboptimal syphilis screening during pregnancy has been identified as a key contributing factor.

METHODS

This study aimed to explore, from the perspective of multidisciplinary healthcare providers (HCPs), the barriers to optimal screening during the antenatal care (ANC) pathway. Semi-structured interviews conducted with 34 HCPs across multiple disciplines practising in south-east Queensland (SEQ) were analysed through a process of reflexive thematic analysis.

RESULTS

Barriers were found to occur at the system level of ANC, through difficulties in patient engagement in care, limitations in the current model of health care delivery and limitations in the communication pathways across health care disciplines; and at the individual HCP level, through HCP knowledge and awareness of epidemiological changes in syphilis in SEQ, and adequately assessing patient risk.

CONCLUSION

It is imperative that the healthcare systems and HCPs involved in ANC address these barriers to improve screening in order to optimise management of women and prevent congenital syphilis cases in SEQ.

Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm

An increasing number of young females are undergoing chest masculinsation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women. Increasing numbers of chest masculinsation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate support.

The impact of midwifery continuity of care on maternal mental health: A narrative systematic review

BACKGROUND

Systematic reviews have shown that midwifery continuity of care programs lead to improvements in birth outcomes for women and babies, but no reviews have focused specifically on the impact of midwifery continuity of care on maternal mental health outcomes.

OBJECTIVE

To systematically review the available evidence on the impact of midwifery continuity of care on maternal mental health during the perinatal period.

METHOD

A systematic search of published literature available through to March 2021 was conducted. A narrative approach was used to examine and synthesise the literature.

RESULTS

The search yielded eight articles that were grouped based on the mental health conditions they examined: fear of birth, anxiety, and depression. Findings indicate that midwifery continuity of care leads to improvements in maternal anxiety/worry and depression during the perinatal period.

CONCLUSION

There is preliminary evidence showing that midwifery continuity of care is beneficial in reducing anxiety/worry and depression in pregnant women during the antenatal period. As the evidence stands, midwifery continuity of care may be a preventative intervention to reduce maternal anxiety/worry and depression during the perinatal period.