The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions

The PRIMROSE Project: What is 'physiological birth'? A quantitative approach to the perceptions of the Australian population

BACKGROUND

The definition of 'physiological birth' by the World Health Organization in 1997 may need to be revisited to better align with current practices in labour and birth in the Australian context, and to better understand the perspectives of women and their care providers. This study explored if obstetric doctors, midwives, doulas, women, and support people (with experience in labour and birth in the last 12 months) recognise physiological birth differently, which interventions they consider congruent with physiological birth, and terms that should be included in a consensus statement of 'physiological birth'.

METHODS

A self-administered, anonymous, 68-field questionnaire was developed and shared online via social media platforms (Facebook, X, and LinkedIn). The questionnaire included Visual Analogue Scales, multi-choice, Likert scale, and open-text items. Data were collected between August - November 2023.

RESULTS

733 participants interacted with the survey. Medical intervention such as vaginal examination to assess labour progress, was considered congruent with physiological birth, whereas continuous cardiotocography and artificial rupture of membranes were considered to be 'non-physiological'. Doulas associated physiological birth with being 'intervention-free' more strongly than any other group. Obstetrics doctors viewed birth as inherently risky. Respondents indicated that the psychological experience of birth, and terms such as 'spontaneous onset', 'no/minimal intervention' and 'spontaneous delivery/birth' should be included in a consensus statement of 'physiological birth'.

CONCLUSION

There are multiple understandings of the term 'physiological birth', implying that the term lacks clarity. There are disparities in how care providers and women view intervention in birth; suggesting a consensus statement of 'physiological birth' is appropriate for the Australian context.

Validation of the Birth Beliefs Scale for maternity care professionals in The Netherlands

OBJECTIVES

To validate the Birth Beliefs Scale (BBS) for maternity care professionals by testing: (1) content validity; (2) internal reliability; (3) known-group discriminant validity; and examine potential relationships between regions and birth beliefs.

METHODS

First, content validity was tested. Before distribution of the questionnaire among maternity care professionals of six maternity care networks (MCNs), adjustments in the statements were made whenever content validity was too low. Data were collected from November 2022 to March 2023. Statistical analysis was performed using Cronbach's alpha, ANOVA and regression analysis.

RESULTS

Based on the content validity-test, item 6 of the questionnaire was adjusted before distribution. In total, 199 maternity care professionals completed the questionnaire. A good internal reliability of the BBS was found. There was a significant difference between the different disciplines for the BBS-Med subscale (p < .001), and the BBS-Nat subscale (p < .001). For the BBS-Nat subscale, the factors work experience and MCN were significant in the regression analysis, with interaction on the association between BBS-Nat and discipline.

CONCLUSIONS

The BBS is a valid instrument to measure birth beliefs among maternity care professionals. The BBS can help to create awareness within professionals of their beliefs and may help to explain practice variation in childbirth.

Obstetricians and midwives perspective of the alarming high cesarean section rates in Greece and worldwide

Introduction

This study aimed to outline the perspectives of obstetricians/gynecologists (physicians) and midwives regarding the alarmingly high rates of cesarean sections (CSs) to identify areas for improvement and describe the role of a regional obstetric quality initiative.

Material and methods

A cross-sectional study was performed utilizing real-world data from questionaries provided to Greek midwives and obstetricians. Primary outcomes included the attitudes of Greek physicians and midwives toward the CS rates in Greece and around the world, as well as identifying potential solutions for lowering these rates. The secondary outcome was the potential correlation between the answers of the participants and their demographic parameters.

Results

A total of 456 physicians and 234 midwives participated in the survey. Greek CS rates (>50 %) were considered "acceptable" and inevitable by 29.7 % and 32 % of the participants, respectively. Stratified analysis based on profession showed that significantly fewer midwives compared to obstetricians would agree with current CS rates. Participants who had obtained their degrees abroad were more likely to consider all CS rates more justified than physicians and midwives who had graduated from Greek medical schools. For all questions, the younger age subgroups responded in a way toward the non-acceptability of CS rates and favored the implementation of rules and practice control according to guidelines. The responses did not differ significantly between male and female physicians.

Conclusions

Greek midwives, to a greater degree than obstetricians/gynecologists, consider the current CS rates unjustified and agree on the importance of implementing appropriate interventions to reduce them.

What is 'physiological birth'? A scoping review of the perspectives of women and care providers

PROBLEM

Physiological birth was defined by the World Health Organization in 1997, however, clinical practices in childbirth have changed considerably since this time.

BACKGROUND

Ambiguous terms in healthcare such as 'physiological birth' may cause confusion amongst care providers and consumers.

AIM

To identify what is known about physiological birth, and how perceptions of physiological birth manifest in current literature.

METHODS

This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. Four databases were searched using keywords relating to physiological birth. Relevant studies were identified using agreed criteria, and data were extracted and synthesised.

RESULTS

A total of 24 studies met the inclusion criteria for this review. Three connected factors were identified: (1) Physiological birth in a risk-averse system, (2) Dominant voices in birth, and (3) Lack of exposure to physiological birth. No unified universal definition of physiological birth was identified in the literature.

DISCUSSION

'Physiological birth' as a term lacks consistency. A risk-averse healthcare system could be a barrier to physiological birth. Dominant voices in the birthing space can dictate the way birth occurs. Lack of exposure to physiological birth may diminish the acquisition and maintenance of important skills and knowledge among care providers. Recognising the factors important to women could lead to a positive birth experience.

CONCLUSION

Excluding a woman's subjective experience from health professionals' understanding of physiological birth increases the likelihood of risk management being the paramount objective in clinical decision-making. We propose it is timely to align clinical understanding of physiological birth with midwifery's woman-centred professional philosophy.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives

PROBLEM

The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities.

BACKGROUND

Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma.

AIM

To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives.

METHODS

A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables.

FINDINGS

data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001).

DISCUSSION

This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern.

CONCLUSION

Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study

PROBLEM

Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions.

BACKGROUND

Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth.

AIM

We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians.

METHODS

The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews.

FINDINGS

The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process.

DISCUSSION

The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice.

CONCLUSION

Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

The effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork-a cross-sectional study

INTRODUCTION

The aim of this study was to investigate the effect of organizational belonging and profession on clinicians' attitudes toward supporting vaginal birth and interprofessional teamwork in Swedish maternity care.

MATERIAL AND METHODS

The study used a cross-sectional design, with a web-based survey sent to midwives, physicians and nurse assistants at five labor wards in Sweden. The survey consisted of two validated scales: the Swedish version of the Labor Culture Survey (S-LCS), measuring attitudes toward supporting vaginal birth, and the Assessment of Collaborative Environments (ACE-15), measuring attitudes toward interprofessional teamwork. Two-way ANOVA was conducted to assess the main effect of and interaction effect between organizational belonging and profession for the different subscales of the S-LCS and the ACE-15, together with Tukey's honest significant difference post-hoc analysis and partial eta squared to determine effect size. The relation between the subscales was assessed using the Pearson's correlation analysis.

RESULTS

A total of 539 midwives, physicians and nurse assistants completed the survey. Organizational belonging significantly influenced attitudes toward supporting vaginal birth and interprofessional teamwork, with the largest effect for Positive team culture (F = 38.88, effect size = 0.25, p < 0.001). The effect of profession was strongest for the subscale Best practices (F = 59.43, effect size = 0.20, p < 0.001), with midwives being more supportive of strategies proposed to support vaginal birth than physicians and nurse assistants. A significant interaction effect was found for four of the subscales of the S-LCS, with the strongest effect for items reflecting the Unpredictability of vaginal birth (F = 4.49, effect size = 0.07, p < 0.001). Labor ward culture (unit microculture) specifically related to supporting vaginal birth was strongly correlated to interprofessional teamwork (r = 0.598, p < 0.001).

CONCLUSIONS

In the current study, both organizational belonging and profession influenced attitudes toward supporting vaginal birth and interprofessional teamwork. Positive team culture was positively correlated to an organizational culture supportive of vaginal birth. Interventions to support vaginal births should include efforts to strengthen teamwork between professions, as well as considering women's values, preferences and informed choices.

Obstetric provider preferences for cesarean delivery on maternal request in uncomplicated pregnancies: a systematic review of the literature

OBJECTIVE

The aim of this study is to review obstetric providers' personal preferences for cesarean delivery on maternal request (CDMR) in uncomplicated pregnancies.

DATA SOURCES

Searches were performed in Ovid-Medline, Cochrane, Scopus, CINAHL with terms related to "cesarean," "elective," "scheduled," "maternal request," "physician," "obstetrician," "gynecologist," "midwife," "specialist," and "trainee." There were no limitations placed on the language, year, or location of the studies included in the initial search strategy.

STUDY ELIGIBILITY CRITERIA

Articles were included if they focused on providers' personal preference for CDMR, if they were written in or translated into English, and if they did not meet any exclusion criteria.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was the percentage of providers preferring CDMR in a hypothetical uncomplicated nulliparous term singleton vertex (NTSV) pregnancy. Secondary outcomes included the percentage of providers preferring CDMR for a close family member in a NTSV pregnancy as well as the percentage of providers having a personal history of CDMR.

RESULTS

34 articles were included in the review. The studies were performed across a range of time and geographical locations. The main providers studied were obstetrician-gynecologists (ob-gyns) and midwives. In the hypothetical scenario asking their personal delivery preference for a NTSV pregnancy, the overall preference for CDMR among all obstetric providers was 13.5% (966/7154), specifically 14.3% (894/6250) of ob-gyns and 2% (11/574) of midwives; these percentages increased over the last 20 years. In the hypothetical scenario asking their delivery preference for a close family member in a NTSV pregnancy, these percentages changed to 28.5% (138/484), 67% (138/206), and 0% (0/278), respectively. The percentage of providers with a personal history of CDMR was overall 20.9% (486/2324), specifically 25.2% (338/1339) of ob-gyns, and 2% (7/347) of midwives.

CONCLUSIONS

14.3% of ob-gyns would prefer CDMR for themselves in a hypothetical NTSV pregnancy, and this percentage has increased over the last 20 years. However, 25.2% of ob-gyns have had CDMR themselves, and 67% would recommend it for a close family member. Instead, ≤2% of midwives have had or would recommend CDMR.

Feelings of being a second victim among Spanish midwives and obstetricians

Aim

The aim of this study was to determine the prevalence of feelings of being a second victim among midwives and obstetricians in Spain and to explore possible differences between the two professions.

Design

Cross‐sectional descriptive‐analytical observational study.

Methods

An online survey collecting several variables was administered throughout the Spanish territory. Spanish version of the Second Victim Experience and Support Tool (SVEST) was used. The data collection period was from May to December 2020.

Results

A total sample of 719 obstetricians and midwives were studied. There were significant differences between the two groups with respect to seven dimensions of SVEST: greater feelings of being a second victim among obstetricians in the dimensions physical distress/p ≤ .001, non‐work‐related support/p ≤ .001 and absenteeism/p ≤ .001 and greater feelings of being a second victim among midwives in the dimensions psychological distress/p ≤ .001, supervisor support/p = .011, professional self‐efficacy/p ≤ .001 and intention to change jobs/p ≤ .001.