"If I'm not getting oxygen, neither is my baby": A qualitative study of Australian women's experiences of asthma management in pregnancy

BACKGROUND

Optimal management of asthma during pregnancy is an important element in improving maternal and neonatal outcomes. Asthma effects 12.7 % of pregnant women in Australia. Despite consistent management recommendations available via clinical practice guidelines for asthma in pregnancy, pregnant women with asthma are not receiving guideline recommended care. This study builds on previous research and aims to explore the asthma management experiences of pregnant women with asthma. Specifically, to gain insight into pregnant women's understanding of their asthma; previous and current exposure to asthma education; and attitudes towards their asthma management and medication use.

METHODS

This qualitative descriptive study involved individual semi-structured interviews with pregnant women with asthma. Data were transcribed and analysed using content analysis. The participants were recruited from those enrolled in the Breathing For Life Trial (BLT), an RCT of inflammation-guided asthma management in pregnancy versus usual care.

RESULTS

A total of 24 women were interviewed between June 2018 and May 2020. Three main themes: "Did not think asthma was an issue", "If I'm not getting oxygen in then neither is my baby" and "Beyond pregnancy care" were identified along with 9 sub-themes which showed asthma knowledge, attitude and medication adherence variation depending on experiences with asthma management.

CONCLUSIONS

This study highlighted the varied experiences of this cohort of pregnant women with asthma and identified the need for ongoing consistent asthma management to improve the knowledge, attitude, and medication adherence of women with asthma before during and after pregnancy, and in turn improve maternal and neonatal outcomes.

Antenatal asthma management by midwives in Australia - Self-reported knowledge, confidence and guideline use

BACKGROUND

Asthma affects approximately 12.7% of pregnant women in Australia. Increased maternal and infant morbidity is closely associated with poorly controlled asthma during pregnancy. Midwives are well placed to provide antenatal asthma management but data on current asthma management during pregnancy is not available, nor is the use of guidelines for clinical practice by this health professional group.

AIM

To explore self-reported antenatal asthma management provided by midwives across Australia and how this reflects guideline recommendations.

METHOD

An online survey was developed and distributed throughout Australia via the Australian College of Midwives, social media and healthcare facilities.

RESULTS

Responses from 371 midwives were obtained. Ten percent of midwives rated their knowledge as 'good' and 1% as 'very good', with 39% 'poor' or 'very poor'. Being 'somewhat' or 'not at all' confident to provide antenatal asthma management was noted by 87% of midwives. Clinical guidelines were referred to by 50% of midwives and 40% stated that their main role was to refer women to other healthcare professionals. Only 54% reported that a clear referral pathway existed. Most respondents (>90%) recognised key recommendations for asthma management such as smoking cessation, appropriate vaccinations, and the continuation of prescribed asthma medications.

CONCLUSION

Although midwives appear aware of key clinical recommendations for optimal antenatal asthma management, low referral to clinical practice guidelines and lack of knowledge and confidence was evident. Further research is required to determine what care pregnant women with asthma are actually receiving and identify strategies to improve antenatal asthma management by midwives.

The Breathing for Life Trial: a randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health

BACKGROUND

Asthma exacerbations are common during pregnancy and associated with an increased risk of adverse perinatal outcomes. Adjusting asthma treatment based on airway inflammation rather than symptoms reduces the exacerbation rate by 50 %. The Breathing for Life Trial (BLT) will test whether this approach also improves perinatal outcomes.

METHODS/DESIGN

BLT is a multicentre, parallel group, randomised controlled trial of asthma management guided by fractional exhaled nitric oxide (FENO, a marker of eosinophilic airway inflammation) compared to usual care, with prospective infant follow-up. Women with physician-diagnosed asthma, asthma symptoms and/or medication use in the previous 12 months, who are 12-22 weeks gestation, will be eligible for inclusion. Women randomised to the control group will have one clinical assessment of their asthma, including self-management education. Any treatment changes will be made by their general practitioner. Women randomised to the intervention group will have clinical assessments every 3-6 weeks during pregnancy, and asthma treatments will be adjusted every second visit based on an algorithm which uses FENO to adjust inhaled corticosteroid (ICS) dose (increase in dose when FENO >29 parts per billion (ppb), decrease in dose when FENO <19 ppb, and no change when FENO is between 19 and 29 ppb). A long acting beta agonist (LABA) will be added when symptoms remain uncontrolled. Both the control and intervention groups will report on exacerbations at a postpartum phone interview. The primary outcome is adverse perinatal outcome (a composite measure including preterm birth, intrauterine growth restriction, neonatal hospitalisation at birth or perinatal mortality), assessed from hospital records. Secondary outcomes will be each component of the primary outcome, maternal exacerbations requiring medical intervention during pregnancy (both smokers and non-smokers), and hospitalisation and emergency department presentation for wheeze, bronchiolitis or croup in the first 12 months of infancy. Outcome assessment and statistical analysis of the primary outcome will be blinded. To detect a reduction in adverse perinatal outcomes from 35 % to 26 %, 600 pregnant women with asthma per group are required.

DISCUSSION

This trial will provide evidence for the effectiveness of a FENO-based management strategy in improving perinatal outcomes in pregnant women with asthma. If successful, this would improve the management of pregnant women with asthma worldwide.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000202763 .

Midwives' perception of their role in providing antenatal asthma management in Australia--a qualitative study

International guidelines recommend a collaborative approach to the care of pregnant women with asthma. Midwives, as the primary health care provider for childbearing women should be viewed as collaborative partners in the provision of antenatal asthma management. However, the role of the midwife in providing antenatal asthma management has not been widely reported.

METHOD

Australian midwives' perceived role in antenatal asthma management was studied using a qualitative descriptive method. Semi-structured in-depth interviews were conducted with 13 midwives working in a regional tertiary hospital. Morse and Field's four-stage process was used to analyse the data.

FINDINGS

the perceived role of the midwife in antenatal asthma management varied among participants. Some midwives stated their role was to refer women on to other health professionals. Other midwives stated that they should provide education to the women regarding their asthma management during their pregnancy.

CONCLUSION

participants were uncertain about their role and lacked confidence in antenatal asthma management. The midwifery context in which they worked and the resources available to them at this health care facility appeared to influence the perception of their role.

Managing asthma in pregnancy

Asthma is a common comorbidity during pregnancy and its prevalence is increasing in the community. Exacerbations are a major clinical problem during pregnancy with up to 45% of women needing to seek medical help, resulting in poor outcomes for mothers and their babies, including low birth weight and preterm delivery. The goals of effective asthma management in pregnancy are to maintain the best possible asthma control and prevent exacerbations. This is achieved by aiming to prevent day- and night-time symptoms, and maintain lung function and normal activity. In addition, maintaining fetal oxygenation is an important consideration in pregnancy. Guidelines recommend providing asthma advice and review prior to conception, and managing asthma actively during pregnancy, with regular 4-weekly review, provision of a written action plan, use of preventer medications as indicated for other adults with asthma, and management of comorbid conditions such as rhinitis. Improvements have been made in recent years in emergency department management of asthma in pregnancy, and multidisciplinary approaches are being proposed to optimise both asthma outcomes and perinatal outcomes. One strategy that has demonstrated success in reducing exacerbations in pregnancy is treatment adjustment using a marker of eosinophilic lung inflammation, the exhaled nitric oxide fraction (F eNO). The use of an algorithm that adjusted inhaled corticosteroids (ICS) according to F eNO and added long-acting β-agonists when symptoms remained uncontrolled resulted in fewer exacerbations, more women on ICS but at lower mean doses, and improved infant respiratory health at 12 months of age. Further evidence is needed to determine whether this strategy can also improve perinatal outcomes and be successfully translated into clinical practice.

KEY POINTS

Asthma is the most common chronic disease to affect pregnant women.Exacerbations occur in up to 45% of pregnant women with asthma.Asthma should be managed during pregnancy as for other adults.Treatment adjustment using a marker of airway inflammation reduces the exacerbation rate in pregnancy.

EDUCATIONAL AIMS

To identify the goals of and steps associated with effective asthma management in pregnancy.To understand the maternal and perinatal risks associated with asthma during pregnancy.To describe a management strategy that has been shown to reduce exacerbations in pregnant women with asthma.