Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study

OBJECTIVE

The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]).

METHODS

2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum.

RESULTS

Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care.

CONCLUSION

Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

The sustainability of midwifery group practice: A cross-sectional study of midwives and managers

PROBLEM

Although there is robust evidence for the benefits of midwifery group practice (MGP) caseload care, there are limited opportunities for women to access this model in Australia. There is also limited knowledge on how to sustain these services.

BACKGROUND

MGP can benefit childbearing women and babies and improve satisfaction for women and midwives. However, sustainability of the model is challenging. While MGPs are often supported and celebrated, in Australia some services have closed, while others struggle to adequately staff MGPs.

AIM

To investigate midwives and managers opinions on the management, culture, and sustainability of MGP.

METHODS

A national survey of MGP midwives and managers was distributed (2021 and 2022). Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using content analysis.

RESULTS

A total of 579 midwives and 90 managers completed the survey. The findings suggest that many MGPs do not support new graduates and students to work in MGP. Over half (59.8%) the participants (midwives and managers) reported that the women and families were the best aspect about working in MGP, while 44.3% said the effects on midwives' lifestyle and families were the worst aspect.

DISCUSSION

The relationship with women remains the major motivator for providing MGP care. However, work-life imbalance is a deterrent, exacerbated by staffing shortages. Staffing might be improved by adequate renumeration, strengthening orientation, and attracting new graduates and students through experience in MGP.

CONCLUSIONS

There is a need to attract midwives to MGP and improve work-life balance and sustainability.

Midwives' experiences with PPE during the COVID-19 pandemic: The Birth in the Time of COVID (BITTOC) study

BACKGROUND

The COVID-19 pandemic resulted in rapid changes aimed at reducing disease transmission in maternity services in Australia. An increase in personal protective equipment (PPE) in the clinical and community setting was a key strategy. There was variation in the type of PPE and when it was to be worn in clincial practice.

AIM

This paper reports on Australian midwives' experiences of PPE during the pandemic.

METHODS

This sequential mixed methods study was part of the Birth in the Time of COVID-19 (BITTOC 2020) study. Data were obtained from in-depth semi-structured interviews with midwives in 2020 followed by a national survey undertaken at two time points (2020 and 2021). Qualitative open-text survey responses and interview data were analysed using content analysis.

FINDINGS

16 midwives were interviewed and 687 midwives provided survey responses (2020 n = 477, 2021 n = 210). Whilst midwives largley understood the need for increased PPE, and were mainly happy with this, as it was protective, they reported a number of concerns. These included: inconsistency with PPE type, use, availability, quality, fit and policy; the impact of PPE on the physical and psychological comfort of midwives; and the barriers PPE use placed on communication and woman centred care. This at times resulted in midwives working outside of policy.

CONCLUSION

These findings highlight the need for future comprehensive pandemic preparedness that ensures policy and procedure recommendations are consistent and PPE is available, of approriate quality, and individually fitted in order to ensure that Australian maternity services are well placed to manage future pandemics.

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial

BACKGROUND

'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown.

AIM

The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences.

METHODS

A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed.

RESULTS

A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted.

CONCLUSIONS

The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

Incorporating co-design principles and social media strategies to enhance cross-sectional online survey participation: The Birth Experience Study

AIM

To use co-design principles to design a nationwide maternity experiences survey and to distribute the survey through social media.

DESIGN

A co-designed, cross sectional, and national online survey.

METHODS

Using co-design principles from study design and throughout the research process a cross-sectional, online, national survey of Australian women's experiences of maternity care was designed. Four validated survey instruments were included in the survey design.

RESULTS

An extensive social media strategy was utilized, which included paid advertising, resulting in 8804 surveys for analysis and 54,896 comments responding to open text questions.

DISCUSSION

The inclusion of co-design principles contributed to a well-designed survey and consumer involvement in distribution and support of the online survey. The social media distribution strategy contributed to high participation rates with overall low marketing costs.

CLINICAL RELEVANCE

Maternity services should be designed to provide woman-centered, individualized care. This survey was co-designed with maternity users and maternity organizations to explore women's recent experiences of maternity care in Australia. The outcomes of this study will highlight the factors that contribute to positive and negative experiences in maternity services.

PATIENT OR PUBLIC CONTRIBUTION

As a co-designed study, there was consumer engagement from the design of the study, throughout the research process.

Investigation of Hypothalamic Pituitary Adrenal Axis and Oxytocinergic System Changes in a Pragmatic Randomized Controlled Feasibility Trial of Acupuncture for Antenatal Depression

Background: Antenatal depression is common and associated with detrimental impacts on women and their families. Disrupted neuroendocrine functioning is reported in women experiencing perinatal mental health disturbances. Preliminary randomized controlled trial (RCT) evidence suggests acupuncture may provide a safe and effective adjunct treatment; however, underlying mechanisms of effect are unclear. We conducted an RCT examination of acupuncture for the management of antenatal depressive symptomologies, which included oxytocinergic and hypothalamic pituitary adrenal (HPA) axis system evaluations. This article reports postintervention changes to cortisol: dehydroepiandrosterone (DHEA) ratios, and oxytocin (OT) hormone concentrations. Methods: Fifty-seven women with Edinburgh Postnatal Depression Scale (EPDS) scores ≥13 were randomized to receive individually tailored depressed specific acupuncture, progressive muscle relaxation (PMR) attention comparator, or treatment as usual (TAU). Weekly 1-h sessions were conducted for 8 weeks (24-31 of pregnancy). Preintervention and postintervention saliva samples were collected. Results: Postintervention mean cortisol: DHEA ratio differences were not significantly predicted by group allocation (n = 46, p = 0.065). Two-group comparisons demonstrated cortisol: DHEA ratios were significantly increased and predicted by group allocation when acupuncture was compared to TAU (p = 0.039); however, not between acupuncture and PMR (p = 0.179), or PMR and TAU (p = 0.421). Postintervention OT concentrations were not significantly predicted by group allocation. Limitations: Small sample size and posthoc analysis Conclusion: Findings suggest positive regulation of the HPA axis may be an underlying mechanism by which acupuncture provided the significant improvements to antenatal depression, stress, and distress observed in this cohort. Trial Registration: Registered on March 19, 2015, with the Australian New Zealand Clinical Trials Registry (ACTRN12615000250538).

Midwifery group practice workforce in Australia: A cross-sectional survey of midwives and managers

BACKGROUND

Despite robust evidence on the benefits of midwifery group practice (MGP), there remains difficulties with implementing and sustaining the model. However, contemporary data on the MGP workforce and how each model has been operationalised are limited. This constrains an understanding of the factors that help or hinder implementation and sustainability of MGP.

AIM

To describe the characteristics of Australian MGPs and the factors that help or hinder sustainability.

METHODS

A national cross-sectional survey was undertaken in Australia between March 2021 and July 2022, inclusive. Quantitative data were analysed using descriptive analysis while qualitative data were analysed using content analysis.

FINDINGS

Of 669 survey responses, 579 were midwives and 90 were managers. The mean years of experience for clinical midwives was eight years, and 47.8% (almost twice the national average) completed a Bachelor of Midwifery (BMid). Half (50.2%) the models provided care for women of all risk. Midwives resigned from MGP because of the MGP work conditions (30%) and how the service was managed or supported (12.7%). Managers resigned from MGP because of role changes, conflict with their manager, and limited support. Almost half (42.6%) of MGP managers also managed other areas, leading to heavy workloads, competing demands, and burnout.

CONCLUSION

The BMid appears to be a common educational pathway for MGP midwives, and many MGP services are providing care to women with complexities. Flexible practice agreements, organisational support and appropriate workloads are vital for recruitment, retention, and sustainability of MGP.

A content analysis of women's experiences of different models of maternity care: the Birth Experience Study (BESt)

BACKGROUND

Pregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.

METHODS

The data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.

RESULTS

In models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).

CONCLUSIONS

Women across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.

TRIAL REGISTRATION

The study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP .

Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial

BACKGROUND

Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor.

METHODS

This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data.

RESULTS

The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive.

CONCLUSIONS

Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.

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.

What women want if they were to have another baby: the Australian Birth Experience Study (BESt) cross-sectional national survey

OBJECTIVES

To explore if Australian women would do anything differently if they were to have another baby.

DESIGN AND SETTING

The Birth Experience Study (BESt) online survey explored pregnancy, birth and postnatal experiences for women who had given birth during 2016-2021 in Australia.

PARTICIPANTS

In 2021, 8804 women responded to the BESt survey and 6101 responses to the open text responses to the survey question 'Would you do anything different if you were to have another baby?' were analysed using inductive content analysis.

RESULTS

A total of 6101 women provided comments in response to the open text question, resulting in 10 089 items of coding. Six categories were found: 'Next time I'll be ready' (3958, 39.2%) described how women reflected on their previous experience, feeling the need to better advocate for themselves in the future to receive the care or experience they wanted; 'I want a specific birth experience' (2872, 28.5%) and 'I want a specific model of care' (1796, 17.8%) highlighted the types of birth and health provider women would choose for their next pregnancy. 'I want better access' (294, 2.9%) identified financial and/or geographical constraints women experience trying to make choices for birth. Two categories included comments from women who said 'I don't want to change anything' (1027, 10.2%) and 'I don't want another pregnancy' (142, 1.4%). Most women birthed in hospital (82.9%) and had a vaginal birth (59.2%) and 26.7% had a caesarean.

CONCLUSION

Over 85% of comments left by women in Australia were related to making different decisions regarding their next birth choices. Most concerningly women often blamed themselves for not being more informed. Women realised the benefits of continuity of care with a midwife. Many women also desired a vaginal birth as well as better access to birthing at home.

Prenatal maternal stress was not associated with birthweight or gestational age at birth during COVID-19 restrictions in Australia: The BITTOC longitudinal cohort study

BACKGROUND

Various forms of prenatal maternal stress (PNMS) have been reported to increase risk for preterm birth and low birthweight. However, the associations between specific components of stress - namely objective hardship and subjective distress - and birth outcomes are not well understood.

AIMS

Here, we aimed to determine the relationship between birthweight and gestational age at birth and specific prenatal factors (infant gender and COVID-19 pandemic-related objective hardship, subjective distress, change in diet), and to determine whether effects of hardship are moderated by maternal subjective distress, change in diet, or infant gender.

MATERIALS AND METHODS

As part of the Birth in the Time of COVID (BITTOC study), women (N = 2285) who delivered in Australia during the pandemic were recruited online between August 2020 and February 2021. We assessed objective hardship and subjective distress related to the COVID pandemic and restrictions, and birth outcomes through questionnaires that were completed at recruitment and two months post-partum. Analyses included hierarchical multiple regressions.

RESULTS

No associations between maternal objective hardship or subjective distress and gestational age at birth or birthweight were identified. Lower birthweight was significantly associated with female gender (adjusted β = 0.083, P < 0.001) and with self-reported improvement in maternal diet (adjusted β = 0.059, P = 0.015).

CONCLUSIONS

In a socioeconomically advantaged sample, neither objective hardship nor subjective distress related to COVID-19 were associated with birth outcomes. Further research is warranted to understand how other individual factors influence susceptibility to PNMS and how these findings are applicable to women with lower socioeconomic status.

The implementation and evaluation of a mentoring program for Bachelor of Midwifery students in the clinical practice environment

AIM

To describe the implementation and evaluation of a midwife/midwifery student-mentoring program in one Local Health District in Sydney NSW Australia.

BACKGROUND

Evidence suggests well designed and supported midwife/midwifery student mentorship programs can make a difference to the clinical placement experiences and attrition rates of midwifery students.

DESIGN

In the evaluation of the mentoring program, we used surveys, focus groups and individual interviews.

METHODS

Eighty-six participants, including midwife mentors, midwifery students, non-mentor midwives and midwifery managers participated in the evaluation. Quantitative data were analysed using descriptive statistics and qualitative data, content analysis.

RESULTS

The mentoring program increased midwives' mentoring skills and was beneficial to their professional growth and leadership skills. Students reported positive outcomes including someone to talk to, emotional support and a sense of belonging. Mentoring programs require structure, mentor training, organisational support and transparency.

CONCLUSION

The mentoring program provided benefits to both midwifery mentors and students and demonstrated the value of a structured and supported mentoring program for midwifery students.

Vaccine intention and hesitancy among Australian women who are currently pregnant or have recently given birth: the Birth in the Time of COVID-19 (BITTOC) national online survey

OBJECTIVE

To examine the prevalence of COVID-19 vaccination, and factors associated with vaccination intention and hesitancy in pregnant and postnatal women in Australia.

DESIGN AND SETTING

A national online survey was conducted over 6 months between 31 August 2021 and 1 March 2022 and responses to vaccination status were categorised as: 'vaccinated', 'vaccine intended' and 'vaccine hesitant'. The data were weighted to reflect the proportion of women of reproductive age. Potential confounding variables were examined using multinomial logistic regression analyses, and all comparisons were made against vaccinated pregnant and postnatal women.

PARTICIPANTS

2140 women responded to the survey (838 pregnant; 1302 recently post partum).

RESULTS

Amongst pregnant women, 586 (69.9%) were vaccinated, 166 (19.8%) indicated intention and 86 (10.3%) were hesitant. In postnatal women, this was 1060 (81.4%), 143 (11.0%) and 99 (7.6%), respectively. Only 52 (6.2%) of pregnant women stated never wanting a COVID-19 vaccine. Vaccine hesitancy increased over time, and for pregnant women was associated with: living in a state other than New South Wales (NSW) (Adjusted Relative Risk (ARR) 2.77, 95%CI: 1.68-4.56 for vaccine intention and ARR=3.31, 95%CI: 1.52-7.20 for vaccine hesitancy), younger age <30 years, not having a university education, income <80K AUD, gestation <28 weeks, having no pregnancy risk factors, and being less satisfied with life (ARR=2.20, 95%CI: 1.04-4.65 for vaccine intention and ARR=2.53, 95%CI: 1.02-6.25 for vaccine hesitancy) . For postnatal women: living in a state other than NSW or Victoria, income <80K AUD and having private obstetric care (ARR=2.06, 95%CI: 1.23-3.46) were significantly associated with vaccine hesitancy.

CONCLUSIONS

Around 1 in 10 pregnant women and just over 1 in 13 postnatal women reported vaccine hesitancy in this Australian survey, and hesitancy was higher in the latter 3-month period. Tailored messages to younger mothers and those from lower-middle socioeconomic groups, alongside advice from midwives and obstetricians, could help to reduce hesitancy among pregnant and postnatal women. Financial incentives may help to facilitate COVID-19 vaccine uptake. A real-time surveillance system and additional pregnancy fields added to the Australian immunisation register would support the safety monitoring of multiple vaccines in pregnancy and may build confidence.

How Do Anxiety and Relationship Factors Influence the Application of Childbirth Education Strategies During Labor and Birth: A Bowen Family Systems Perspective

The effectiveness of childbirth education (CBE) has long been debated with studies showing contradictory outcomes for mothers and babies. Understanding how what is learned in CBE is translated into practice during labor and birth is an area that requires investigation as this may be a mediating factor in its effectiveness. Bowen family system theory's concept of differentiation of self, the ability to be guided by and to act from one's beliefs and values, is an organizing principle that may affect how relational factors affect the use and application of CBE at the time of birth. The ability to act with emotional maturity when faced with a stressor, such as childbirth, depends on an individual's capability to separate thoughts from the more reactive feeling process. Recognizing how one's level of differentiation interacts with the anxious responses of others may assist pregnant women and birth partners to make decisions more objectively about how they want to manage the birthing process. For the health professional, understanding the interplay of relationship variables, physiological stress, anxiety and individual reactivity may allow for the provision of more thoughtful evidence-based practice, which may increase objectivity, and aid communication and decision-making for women during birth. Bowen theory, as a comprehensive systems-based approach to understanding human functioning under stress, offers a novel approach to exploring the application of CBE during birth.

The Impact of Mode of Birth, and Episiotomy, on Postpartum Sexual Function in the Medium- and Longer-Term: An Integrative Systematic Review

(1) Background: Sexual function can be affected up to and beyond 18 months postpartum, with some studies suggesting that spontaneous vaginal birth results in less sexual dysfunction. This review examined the impact of mode of birth on sexual function in the medium- (≥6 months and <12 months postpartum) and longer-term (≥12 months postpartum). (2) Methods: Literature published after January 2000 were identified in PubMed, Embase and CINAHL. Studies that compared at least two modes of birth and used valid sexual function measures were included. Systematic reviews, unpublished articles, protocols and articles not written in English were excluded. Quality was assessed using the Newcastle Ottawa Scale. (3) Results: In the medium-term, assisted vaginal birth and vaginal birth with episiotomy were associated with worse sexual function, compared to caesarean section. In the longer-term, assisted vaginal birth was associated with worse sexual function, compared with spontaneous vaginal birth and caesarean section; and planned caesarean section was associated with worse sexual function in several domains, compared to spontaneous vaginal birth. (4) Conclusions: Sexual function, in the medium- and longer-term, can be affected by mode of birth. Women should be encouraged to seek support should their sexual function be affected after birth.

Long-term effectiveness of the midwifery initiated oral health-dental service program on maternal oral health knowledge, preventative dental behaviours and the oral health status of children in Australia

BACKGROUND

The Midwifery Initiated Oral Health-Dental Service was developed to train midwives to promote maternal oral health, and a large trial showed it substantially improved the oral health, knowledge and behaviours of pregnant women.

AIM

Evaluate the long-term effectiveness of the program (post-trial) on maternal oral health knowledge, dental behaviours, and early childhood caries in offspring.

METHODS

A prospective cohort study involving 204 women and children 3-4 years (followed after trial) was conducted in Sydney, Australia from 2017 to 2019.

RESULTS

The program did not have a significant impact on the study measures. Mothers who received the program did have comparatively better knowledge around preventative behaviours to reduce early childhood caries and significantly more mothers were engaging in a key behaviour of using a cup to feed their child. Overall maternal oral health knowledge and level of education did have a protective effect on the dental decay of children. Higher knowledge and levels of education reduced the odds of having a dmft of one or more by over half (OR 0.473), and almost 80% (OR 0.212) respectively.

CONCLUSIONS

Although the MIOH-DS program was not effective, there is still value in exploring other complementary interventions to improve maternal oral health, especially for disadvantaged families. Future research should focus on co-designing an antenatal and postnatal oral health intervention and exploring its long-term impact on the oral health of children.

A national survey of Australian midwives' birth choices and outcomes

BACKGROUND

Maternity care in Australia is predominantly provided by midwives, many who give birth. There is a paucity of research on midwives' own childbearing preferences and experiences.

AIM

To explore midwives childbirth preferences and outcomes when giving birth to their first child in Australia, after qualifying as a midwife.

METHODS

An online national survey. Data were analysed using descriptive statistics.

FINDINGS

447 midwives responded, with the majority of midwives indicating a preference for a normal vaginal birth with a known care provider under a continuity of midwifery care model. For midwives who were first time mothers, 66% had normal vaginal births, 16.3% had an instrumental birth, and 16.8% had caesarean births. Over 85% of midwives received the model of care they wanted and 45% had continuity of midwifery care. While a quarter of midwives wanted a homebirth,11.2% achieved this. Over three quarters (75.4%) of midwives were cared for by a care provider of their choosing.

DISCUSSION

There was a difference in models of care accessed and birth outcomes between midwives and other women giving birth for the first-time in Australia. Australian midwives appear to have the advantage of clinical and scientific knowledge to navigate the maternity care system to get the birth care and outcomes they want.

CONCLUSION

It is possible that professional experience, insider knowledge, and existing relationships with other midwifery friends and colleagues, affords midwives a higher degree of agency and autonomy when it comes to getting the maternity care and birth outcomes that they want.

"You are either with me on this or not": A meta-ethnography of the influence birth partners and care-providers have on coping strategies learned in childbirth education and used by women during labour

BACKGROUND

Childbirth education, which includes providing information and practical techniques to help manage childbirth, aims to support women and their birth partners. It is unknown how birth partners and care providers influence the utilisation of childbirth education information and techniques during women's labour and birth.

AIM

To explore the literature that investigates the influence that birth partners and care-providers have on the application of childbirth education information and techniques used by women during childbirth.

METHODS

A meta-ethnography was performed using a systematic synthesis of reciprocal translation and refutational investigation. There were 22 papers included in the final synthesis. Quality appraisal was undertaken using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBIQARI) quality appraisal tool for qualitative studies.

FINDINGS

An over-arching theme of 'you are either with me on this or not' emerged from the data, which expressed the positive and negative influences on the use of childbirth education information and techniques during labour and birth. The influence of birth partners was captured in the themes 'stepping up to their full potential' and 'a spare part'. The themes 'in alignment with the woman' and 'managed by another' were conceptualised from the data in relation to care-providers' influence. A theme, 'the right fit', described organisational and contextual influences.

CONCLUSION

Birth partners and care-providers who are present during a woman's labour have significant potential to influence her use of childbirth education strategies in labour, which provides important insights for translation of evidence into practice.

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.

Model of care matters: An integrative review

BACKGROUND

Pregnant women are entitled to quality care during pregnancy. Some health districts offer a variety of maternity care models but, not all women are aware of what is available and there is limited research on the experiences of women within their chosen or allocated model of care.

AIM

The aim of this integrative review is to explore the available literature on women's experiences of the model of care accessed during pregnancy.

METHOD

A database search of CINAHL, MEDLINE, SCOPUS, OVID, JBI and Cochrane Database was conducted to identify original research articles published in English between 2011 and 2021. In total, 20 articles met the inclusion criteria.

FINDINGS

The included papers came from nine different countries and reported on eight different models of care. Following analysis of the articles one overarching theme 'Model of care matters', and six sub themes were identified: 1.'Choosing a model', 2.'Learning about pregnancy and birth', 3.'Being known', 4.'Making social and emotional connections', 5.'Receiving enabling or disabling care' and 6.'Integrated care is best'. Some women disclosed that they had no choice in the model they were allocated, while others stated they were not provided with information about all available models of care.

CONCLUSION

A lack of integrated care between medical and midwifery models led to feelings of dissatisfaction and distress during pregnancy. Positive experiences were reported when women developed a connection with the care provider. The development of a well-informed decision aid could alleviate deficits of information, and clarify the subtle differences that occur within various models.

Why freebirth in a maternity system with free midwifery care? A qualitative study of Danish women's motivations and preparations for freebirth

OBJECTIVE

Even in maternity care systems with free midwifery care, some women intentionally choose to birth unattended by any health professional (freebirth). Women who choose freebirth represent an enigma for many, and a provocation to some. However, people who do not conform to dominant medical practices are a source of valuable insights that can reveal shortcomings in the mainstream health care system. Thus, the aim of this study was to explore and understand women's motivations and preparations for freebirth.

METHODS

The study was informed by the theoretical lens of the 'undisciplined patient'. Qualitative, in-depth interviews were performed with ten Danish women, who for their most recent birth had planned to freebirth. Data were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. "The standard system is not for me" describes negative experiences during previous births and the desire for more individualised support. "Re-establishing trust in myself" describes the women's quest for recognizing their own needs and re-building autonomy and inner strength. "I do my research" describes how the women sought new ways of knowing and prioritised experiential knowledge. And finally, "I create my safe space" describes the women's efforts to create the best possible physical and emotional space for themselves and their babies in order to have a safe and autonomous birth experience.

CONCLUSION

Freebirth is not undertaken lightly or without preparation by women. Improved continuity of care as well as greater flexibility in hospital guidelines could accommodate some of these women's demand for autonomy in birth.

Dehumanized, Violated, and Powerless: An Australian Survey of Women's Experiences of Obstetric Violence in the Past 5 Years

Globally, significant numbers of women report obstetric violence (OV) during childbirth. The United Nations has identified OV as gendered violence. OV can be perpetrated by any healthcare professional (HCP) and is impacted by systemic issues such as HCP education, staffing ratios, and lack of access to continuity of care. The current study explored the experiences of OV reported in a national survey in 2021 by Australian women who had a baby in the previous 5 years. A content analysis of 626 open text comments found three main categories: "I felt dehumanised," "I felt violated," and "I felt powerless." Women reported bullying, coercion, non-empathic care, and physical and sexual assault. Disrespect and abuse and non-consented vaginal examinations were the subcategories with the most comments.

Prenatal stress from the COVID-19 pandemic predicts maternal postpartum anxiety as moderated by psychological factors: The Australian BITTOC Study

BACKGROUND

While there have been reports of increased perinatal anxiety during the COVID-19 pandemic (Stepowicz et al., 2020), there has been a lack of research on the relative importance of objective hardship and subjective distress. In this study, we explored the extent to which resilience, tolerance of uncertainty, and cognitive appraisal of the pandemic's consequences moderate the effect of prenatal objective hardship and subjective distress due to the pandemic on 2-month postpartum anxiety.

METHODS

Data were collected as part of the Birth in the Time of COVID (BITTOC) study. We measured objective hardship and subjective distress, mental health, and potential psychological moderators in 419 pregnant women residing in Australia, and at two months postpartum. Hierarchical multiple regressions were used.

RESULTS

Objective hardship and subjective distress independently predicted postpartum anxiety. All three psychological factors moderated the effect of objective hardship on anxiety. For women with low/neutral resilience, or low/moderate tolerance of uncertainty, or a negative cognitive appraisal, greater objective hardship predicted higher postpartum anxiety. Conversely, for women with high resilience, or high tolerance of uncertainty, or neutral/positive cognitive appraisal, there was no association. Only a neutral/positive cognitive appraisal significantly buffered the effect of subjective distress on anxiety.

LIMITATIONS

Participants self-selected themselves into the study. The generalizability of our results could be restricted to women of higher socio-economic status.

CONCLUSIONS

These findings help us better understand options for intervention and assessment of vulnerable women during times of stress, along with the mechanisms by which COVID-related stress during pregnancy contributes to postpartum anxiety.

Midwife-centred management: a qualitative study of midwifery group practice management and leadership in Australia

Background

Midwifery group practice (MGP) has consistently demonstrated optimal health and wellbeing outcomes for childbearing women and their babies. In this model, women can form a relationship with a known midwife, improving both maternal and midwife satisfaction. Yet the model is not widely implemented and sustained, resulting in limited opportunities for women to access it. Little attention has been paid to how MGP is managed and led and how this impacts the sustainability of the model. This study clarifies what constitutes optimal management and leadership and how this influences sustainability.

Methods

This qualitative study forms part of a larger mixed methods study investigating the management of MGP in Australia. The interview findings presented in this study are part of phase one, where the findings informed a national survey. Nine interviews and one focus group were conducted with 23 MGP managers, clinical midwife consultants, and operational/strategic managers who led MGPs. Transcripts of the audio-recordings were analysed using inductive, reflexive, thematic analysis.

Results

Three themes were constructed, namely: The manager, the person, describing the ideal personal attributes of the MGP manager; midwifing the midwives, illustrating how the MGP manager supports, manages, and leads the group practice midwives; and gaining acceptance, explaining how the MGP manager can gain acceptance beyond group practice midwives. Participants described the need for MGP managers to display midwife-centred management. This requires the manager to have qualities that mirror what is generally accepted as requirements for good midwifery care namely: core beliefs in feminist values and woman-centred care; trust; inclusiveness; being an advocate; an ability to slow down or take time; an ability to form relationships; and exceptional communication skills. Since emotional labour is a large part of the role, it is also necessary for them to encourage and practice self-care.

Conclusions

Managers need to practice in a way that is midwife-centred and mimics good midwifery care. To offset the emotional burden and improve sustainability, encouraging and promoting self-care practices might be of value.

Insider knowledge as a double-edged sword: an integrative review of midwives' personal childbearing experiences

BACKGROUND

The majority of maternity care is provided by female midwives who have either become mothers or are of childbearing age, but there is limited research exploring midwives' own personal childbearing experiences. This integrative review aims to explore the published literature and research on midwives' own experiences of pregnancy and childbirth.

METHOD

An integrative review of the literature was conducted after relevant articles were identified through a search of: five electronic databases (Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar), cited reference lists, and networking with peers. Similar and contrasting patterns and relations within the literature were identified and grouped into themes and subthemes.

RESULTS

Twenty articles were included in the review and four overarching themes were identified. Insider knowledge plays a role in decision making encompassed the way midwives used their knowledge to choose; a preferred mode of birth, maternity care provider, model of care, and place of birth. Navigating the childbirth journey demonstrated how some midwives were able to use their insider knowledge to achieve agency, while others had difficulty achieving agency. This theme also revealed the 'midwife brain' that midwives need to manage during their childbearing journey. The theme impact of care on the birth experience described how the type of care the midwives received from maternity care providers affected their overall birth experience. The fourth theme from midwife to mother explains their preparedness for childbirth and their transition to motherhood.

CONCLUSION

For childbearing midwives, there is a potential conflict between their position as knowledgeable experts in maternity care, and their experience as mothers. Whilst they can use their insider knowledge to their advantage, they also experience heightened fear and anxiety through their pregnancy. It is important for maternity care providers to acknowledge and support them and provide balanced and tailored care that acknowledges the woman within the professional midwife and the professional midwife within the woman.

The Impact of Mode of Birth on Childbirth-Related Post Traumatic Stress Symptoms beyond 6 Months Postpartum: An Integrative Review

(1) Background: A traumatic birth can lead to the development of childbirth-related posttraumatic stress symptoms or disorder (CB-PTS/D). Literature has identified the risk factors for developing CB-PTS/D within the first six months postpartum thoroughly. However, the impact of mode of birth on CB-PTS/D beyond 6 months postpartum is scarcely studied. (2) Methods: A systematic search of the literature was conducted in the databases PubMed, Embase and CINAHL and PRISMA guidelines were followed. Studies were included if they reported the impact of mode of birth on CB-PTS/D beyond 6 months postpartum. (3) Results: In total, 26 quantitative and 2 qualitative studies were included. In the quantitative studies the percentage of women with CB-PTS/D ranged from 0.7% to 42% (between six months and five years postpartum). Compared with vaginal birth, operative vaginal birth, and emergency caesarean section were associated with CB-PTS/D beyond 6 months postpartum. Qualitative studies revealed that some women were suffering from CB-PTS/D as long as 18 years after birth. (4) Conclusions: Long- term screening of women for PTSD in the postnatal period could be beneficial. More research is needed on models of care that help prevent CB-PTS/D, identifying women at risk and factors that maintain CB-PTS/D beyond 6 months postpartum.

Efficacy of Direct or Indirect Use of Probiotics for the Improvement of Maternal Depression during Pregnancy and in the Postnatal Period: A Systematic Review and Meta-Analysis

The mother and infant form a unique bond, with maternal mental health affecting the interactions with the infant and infant behaviours impacting maternal mental health. One of the possible mechanisms influencing maternal mental health is the manipulation of the gut-brain axis by consuming probiotic supplements. Probiotics can also have an indirect influence on maternal mental health via the modulation of the infant microbiome and consequently improving the infant’s health and thus, indirectly leading to an improvement in maternal mood. This systematic review evaluated the efficacy of probiotics on maternal mental health by searching for randomised controlled trials via international databases: Cochrane Library, PubMed, Scopus, ScienceDirect, and Web of Science until January 2022. A meta-analysis was performed using the Cochrane Collaboration methodology where possible. We found seven clinical trials that included the word probiotics and addressed maternal depression and/or anxiety. Of these, five trials investigated the influence of maternal probiotic supplementation on the gut-brain axis. Two trials investigated the indirect influence of probiotics on maternal depression via supplementation of probiotics by infants and subsequent influence on the crying of colicky infants. Meta-analysis of two studies of pregnant and postnatal women and two studies of infants consuming probiotics on the outcome of the Edinburgh Postnatal Depression Scale for mothers showed no statistical difference. The findings indicate that maternal depression is very complex and is influenced by various bidirectional factors. One of the factors that can improve maternal mental health is probiotics, however, careful consideration must be given to correct strain selection as strain-specific effectiveness was observed. Further well-designed, robust clinical studies are warranted.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

BACKGROUND

Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.

METHODS

In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.

FINDINGS

Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97).

INTERPRETATION

The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time.

FUNDING

The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

The effect of antenatal pelvic floor muscle exercise on sexual function and labour and birth outcomes: A randomised controlled trial

BACKGROUND

Pelvic floor muscle exercises (PFME) are recommended for treatment of urinary incontinence with less evidence available about the effect on female sexual function (FSF) and childbirth.

AIM

To investigate the effect of antenatal PFME on FSF during pregnancy and the first three months following birth as a primary outcome, and on labour and birth outcomes as a secondary outcome.

METHOD

200 nulliparous women were randomised to control (n = 100) and intervention (n = 100) groups. The women in the intervention group (IG) undertook PFME from 20 weeks gestation until birth and had routine antenatal care, while those in the control group (CG) received routine antenatal care only. The Female Sexual Function Index (FSFI) was used to measure FSF at 36 weeks gestation and three months postnatal. Baseline characteristics and childbirth data were also collected and analysed using SPSS.

RESULTS

There were no statistically significant differences between the two groups in terms of FSF scores during pregnancy and on childbirth outcomes. Sexual satisfaction was slightly higher in the CG [Mean ± SD, CG: 4.35 ± 1.45 vs. IG: 3.70 ± 1.50, (P = 0.03)] at three months after birth. However, 50% of women adhered to the PFME, and 40% of women did not resume sex by three months after the birth.

CONCLUSION

Though some trends were observed, the results showed no effect of PFME on sexual function or labour and birth outcomes. This needs to be interpreted considering the 50% adherence to PFME. More research is recommended.

Routine vaginal examinations compared to other methods for assessing progress of labour to improve outcomes for women and babies at term

BACKGROUND

Routine vaginal examinations are undertaken at regular time intervals during labour to assess whether labour is progressing as expected. Unusually slow progress can be due to underlying problems, described as labour dystocia, or can be a normal variation of progress. Evidence suggests that if mother and baby are well, length of labour alone should not be used to decide whether labour is progressing normally. Other methods to assess labour progress include intrapartum ultrasound and monitoring external physical and behavioural cues. Vaginal examinations can be distressing for women, and overdiagnosis of dystocia can result in iatrogenic morbidity due to unnecessary intervention. It is important to establish whether routine vaginal examinations are effective, both as an accurate measure of physiological labour progress and to distinguish true labour dystocia, or whether other methods for assessing labour progress are more effective. This Cochrane Review is an update of a review first published in 2013.

OBJECTIVES

To compare the effectiveness, acceptability, and consequences of routine vaginal examinations compared with other methods, or different timings, to assess labour progress at term.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings) and ClinicalTrials.gov (28 February 2021). We also searched the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of vaginal examinations compared with other methods of assessing labour progress and studies assessing different timings of vaginal examinations. Quasi-RCTs and cluster-RCTs were eligible for inclusion. We excluded cross-over trials and conference abstracts.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies identified by the search for inclusion in the review. Four review authors independently extracted data. Two review authors assessed risk of bias and certainty of the evidence using GRADE.

MAIN RESULTS

We included four studies that randomised a total of 755 women, with data analysed for 744 women and their babies. Interventions used to assess labour progress were routine vaginal examinations, routine ultrasound assessments, routine rectal examinations, routine vaginal examinations at different frequencies, and vaginal examinations as indicated. We were unable to conduct meta-analysis as there was only one study for each comparison.  All studies were at high risk of performance bias due to difficulties with blinding. We assessed two studies as high risk of bias and two as low or unclear risk of bias for other domains. The overall certainty of the evidence assessed using GRADE was low or very low.  Routine vaginal examinations versus routine ultrasound to assess labour progress (one study, 83 women and babies) Study in Turkey involving multiparous women with spontaneous onset of labour. Routine vaginal examinations may result in a slight increase in pain compared to routine ultrasound (mean difference -1.29, 95% confidence interval (CI) -2.10 to -0.48; one study, 83 women, low certainty evidence) (pain measured using a visual analogue scale (VAS) in reverse: zero indicating 'worst pain', 10 indicating no pain). The study did not assess our other primary outcomes: positive birth experience; augmentation of labour; spontaneous vaginal birth; chorioamnionitis; neonatal infection; admission to neonatal intensive care unit (NICU). Routine vaginal examinations versus routine rectal examinations to assess labour progress (one study, 307 women and babies) Study in Ireland involving women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine rectal examinations, routine vaginal examinations may have little or no effect on: augmentation of labour (risk ratio (RR) 1.03, 95% CI 0.63 to 1.68; one study, 307 women); and spontaneous vaginal birth (RR 0.98, 95% CI 0.90 to 1.06; one study, 307 women). We found insufficient data to fully assess: neonatal infections (RR 0.33, 95% CI 0.01 to 8.07; one study, 307 babies); and admission to NICU (RR 1.32, 95% CI 0.47 to 3.73; one study, 307 babies). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; maternal pain. Routine four-hourly vaginal examinations versus routine two-hourly examinations (one study, 150 women and babies) UK study involving primiparous women in labour at term. We assessed the certainty of the evidence as very low. Compared with routine two-hourly vaginal examinations, routine four-hourly vaginal examinations may have little or no effect, with data compatible with both benefit and harm, on: augmentation of labour (RR 0.97, 95% CI 0.60 to 1.57; one study, 109 women); and spontaneous vaginal birth (RR 1.02, 95% CI 0.83 to 1.26; one study, 150 women). The study did not assess our other primary outcomes: positive birth experience; chorioamnionitis; neonatal infection; admission to NICU; maternal pain. Routine vaginal examinations versus vaginal examinations as indicated (one study, 204 women and babies)  Study in Malaysia involving primiparous women being induced at term. We assessed the certainty of the evidence as low. Compared with vaginal examinations as indicated, routine four-hourly vaginal examinations may result in more women having their labour augmented (RR 2.55, 95% CI 1.03 to 6.31; one study, 204 women). There may be little or no effect on: • spontaneous vaginal birth (RR 1.08, 95% CI 0.73 to 1.59; one study, 204 women); • chorioamnionitis (RR 3.06, 95% CI 0.13 to 74.21; one study, 204 women); • neonatal infection (RR 4.08, 95% CI 0.46 to 35.87; one study, 204 babies); • admission to NICU (RR 2.04, 95% CI 0.63 to 6.56; one study, 204 babies). The study did not assess our other primary outcomes of positive birth experience or maternal pain.

AUTHORS' CONCLUSIONS

Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for a safe and positive labour and birth, and if not, to develop an approach that does.

Probiotics for preventing and treating infant regurgitation: A systematic review and meta-analysis

Infant regurgitation is common during infancy and can cause substantial parental distress. Regurgitation can lead to parental perception that their infant is in pain. Parents often present in general practitioner surgeries, community baby clinics and accident and emergency departments which can lead to financial burden on parents and the health care system. Probiotics are increasingly reported to have therapeutic effects for preventing and treating infant regurgitation. The objective of this systematic review and meta-analysis was to evaluate the efficacy of probiotic supplementation for the prevention and treatment of infant regurgitation. Literature searches were conducted using MEDLINE, CINAHL, and the Cochrane Central Register of Controlled trials. Only randomised controlled trials (RCTs) were included. A meta-analysis was performed using the Cochrane Collaboration methodology where possible. Six RCTs examined the prevention or treatment with probiotics on infant regurgitation. A meta-analysis of three studies showed a statistically significant reduction in regurgitation episodes for the probiotic group compared to the placebo group (mean difference [MD]: -1.79 episodes/day: 95% confidence interval [CI]: -3.30 to -0.27, N = 560), but there was high heterogeneity (96%). Meta-analysis of two studies found a statistically significant increased number of stools per day in the probiotic group compared to the placebo group at 1 month of age (MD: 1.36, 95% CI: 0.99 to 1.73, N = 488), with moderate heterogeneity (69%). Meta-analysis of two studies showed no statistical difference in body weight between the two groups (MD: -91.88 g, 95% CI: 258.40-74.63: I2  = 23%, N = 112) with minimal heterogeneity 23%. Probiotic therapy appears promising for infant regurgitation with some evidence of benefit, but most studies are small and there was relatively high heterogeneity. The use of probiotics could potentially be a noninvasive, safe, cost effective, and preventative positive health strategy for both women and their babies. Further robust, well controlled RCTs examining the effect of probiotics for infant regurgitation are warranted.

The effectiveness and safety of complementary health approaches to managing postpartum pain: A systematic review and meta-analysis

Background

Women experience pain from a number of causes during the postpartum period. Although pharmacological pain relief has shown to be effective, the efficacy of non-pharmacological methods of pain relief will be of interest to breastfeeding women. The aim of this systematic review was to examine the efficacy and safety of complementary approaches to manage postpartum pain.

Methods

A search of English language databases from their inception to 2020 was undertaken for randomised controlled trials and included primiparous and multiparous women who experienced postpartum pain up to two weeks post birth. The primary outcome was pain. The risk of bias was assessed using the Cochrane risk of bias tool.

Results

Thirty trials were included in the review, 25 trials (2,413 women) were included in the meta-analysis. Two trials of massage found a reduction in pain following caesarean birth within the first 24 h post birth (MD -2.64, 95–2.82 to -2.46, 184 women, I² 0%), and at seven days postpartum (MD -1.91, 95%CI -2.42 to -1.40, 2 trials, 120 women I² 37%). Two trials conducted with women receiving an episiotomy found reduction in perineal pain from herbal ointments within 24 h (MD -1.33, 95% CI -.96 to -0.70, 221 women) and at 14 days postpartum (MD -0.74, 95% CI -1.02 to -0.47, 4 trials). Few trials reported on safety, few trials were at an overall low risk of bias, and overall the quality of evidence was very low.

Conclusion

Further high quality trials are needed to determine the safety and effectiveness of herbal ointment and massage during the early postpartum period.

Complementary medicines and therapies in clinical guidelines on pregnancy care: A systematic review

BACKGROUND

There is a need for evidence-based guidance on complementary medicines and therapies (CMT) use during pregnancy due to high prevalence of use and lack of guidance on the balance of benefit and harms.

AIM

Evaluate the extent to which current clinical practice guidelines relevant to Australian healthcare professionals make clear and unambiguous recommendations about CMT use in pregnancy, and synthesise these recommendations.

METHODS

The search included EMBASE, PubMed, the National Health and Medical Research Council's Clinical Practice Guidelines Portal, and websites of Australian maternity hospitals and professional/not-for-profit organisations for published guidelines on pregnancy care. Data were synthesised narratively. Guidelines were appraised by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

FINDINGS

A total of 48 guidelines were found, of which 41% provided recommendations that were not limited to routine vitamin and mineral supplementation. There were wide variations in recommendations, particularly for vitamin D and calcium. There was some consensus on recommending ginger and vitamin B6 for nausea and vomiting, and additional supplementation for women with obesity. Guidelines generally scored poorly in the domains of editorial independence and rigour of development.

DISCUSSION

There is a lack of guidance with regard to appropriate CMT use during pregnancy, which may result in less-than-optimal care. Inconsistency between guidelines may lead to variations in care.

CONCLUSION

Guidelines should include clear and unambiguous guidance on appropriate CMT use during pregnancy, be based on a structured search of the evidence and informed by stakeholder engagement.

Economic evaluation of the Midwifery Initiated Oral Health-Dental Service programme in Australia

OBJECTIVES

To critically evaluate the cost-effectiveness of the Midwifery Initiated Oral Health-Dental Service (MIOH-DS) designed to improve oral health of pregnant Australian women. Previous efficacy and process evaluations of MIOH-DS showed positive outcomes and improvements across various measures.

DESIGN AND SETTING

The evaluation used a cost-utility model based on the initial study design of the MIOH-DS trial in Sydney, Australia from the perspective of public healthcare provider for a duration of 3 months to 4 years.

PARTICIPANTS

Data were sourced from pregnant women (n=638), midwives (n=17) and dentists (n=3) involved in the MIOH trial and long-term follow-up.

COST MEASURES

Data included in analysis were the cost of the time required by midwives and dentists to deliver the intervention and the cost of dental treatment provided. Costs were measured using data on utilisation and unit price of intervention components and obtained from a micro-costing approach.

OUTCOME MEASURES

Utility was measured as the number of Disability Adjusted Life Years (DALYs) from health-benefit components of the intervention. Three cost-effectiveness analyses were undertaken using different comparators, thresholds and time scenarios.

RESULTS

Compared with current practice, midwives only intervention meets the Australian threshold (A$50 000) of being cost-effective. The midwives and accessible/affordable dentists joint intervention was only 'cost-effective' in 6 months or beyond scenarios. When the midwife only intervention is the comparator, the midwife/dentist programme was 'cost-effective' in all scenarios except at 3 months scenario.

CONCLUSIONS

The midwives' only intervention providing oral health education, assessment and referral to existing dental services was cost-effective, and represents a low cost intervention. Midwives' and dentists' combined interventions were cost-effective when the benefits were considered over longer periods. The findings highlight short and long term economic benefits of the programme and support the need for policymakers to consider adding an oral health component into antenatal care Australia wide.

TRIAL REGISTRATION NUMBER

ACTRN12612001271897; Post-results.

Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study

OBJECTIVES

We compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births.

DESIGN

We used population linked data from New South Wales, Australia (2001-2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age.

RESULTS

Of 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years.

CONCLUSION

IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.

Management and sustainability of midwifery group practice: Thematic and lexical analyses of midwife interviews

BACKGROUND

Although there is high-level evidence supporting positive perinatal outcomes for midwifery group practice (MGP) care, not all women can access this model due to a failure to implement or sustain it. The way that MGPs are managed could be an important factor in whether they are successful in the long-term.

AIM

To explore what determines optimal management of MGP in Australia, and the influence it has on sustainability of MGP.

METHODS

Interviews were conducted with MGP midwives (n=8). Transcriptions of the audio recordings were analysed thematically and lexically for triangulation.

FINDINGS

Following a thematic analysis of the data, an over-arching theme emerged - namely - being valued and supported, with three sub-themes: a nice little sweet spot, someone to stand up for you, and building relationships and support beyond the model. This revealed that value and support by all stakeholders, including the midwives themselves, was necessary to sustain an MGP. The lexical analysis revealed the themes: support, the system, and the caseload. This analysis highlighted the importance of the system - specifically, the impact of the institution on how MGP is operationalised.

CONCLUSION

For MGP to be sustained in Australia, it needs to be prioritised, nurtured, and embraced by the whole maternity care system. Management plays an important role in ensuring the right people are employed to pivotal positions and that midwifery-led models of care are valued and supported throughout the system.

Leadership and management in midwifery-led continuity of care models: A thematic and lexical analysis of a scoping review

OBJECTIVE

Although midwifery-led continuity of care is associated with superior outcomes for mothers and babies, it is not available to all women. Issues with implementation and sustainability might be addressed by improving how it is led and managed - yet little is known about what constitutes the optimal leadership and management of midwifery-led continuity models.

DESIGN

Following a systematic search of academic databases for relevant publications, 25 publications were identified. These were analysed, thematically to clarify (dis)similar themes, and lexically, to clarify how words within the publications travelled together.

FINDINGS

The publications were replete with three key themes. First, leadership - important yet challenged. Second, management of organisational change; barriers and enhancers. Third, promotors of sustainable models of care. Complementarily, the lexical analysis suggests that references to midwives and leadership among the publications did not typically travel together, as reported in the publications and were distant to one another, although management was inter-connected to both and to change. Leadership and management were not closely coupled with midwives or relationships with women.

KEY CONCLUSIONS

Midwifery leadership matters and can be enacted irrespective of position or seniority. Midwifery-led continuity of care models can be better managed via a multipronged approach. Improved leadership and management can help sustain such care. Although there was a perceived need for midwifery leadership, there did not seem to be an association between leadership and midwives in the lexical analysis. Many publications focused on the style theory of leadership and the transformational style theory.

IMPLICATIONS FOR PRACTICE

Instead of focusing on leaders and the presumption of a leadership scarcity, it might be more beneficial to start focusing within, looking with a new lens on leadership within midwifery at all levels. It might also be constructive for the profession to investigate a more progressive form of leadership, one that is relational and focuses on leadership rather than on the leader.

Associations Between Mode of Birth and Neuropsychological Development in Children Aged 4 Years: Results from a Birth Cohort Study

The aim of this prospective longitudinal study was to examine the association between Cesarean section (CS) and child development and behavior. The sample consisted of 256 children who were born at term without serious perinatal pathologies. Their development and behavior was assessed at the age of four using Ages and Stages Questionnaire (ASQ-3), Children's Behavior Questionnaire and Strength and Difficulties Questionnaire. Multivariate linear regression analyses were conducted to assess the association between CS and child outcomes. CS was associated with better scores in the Problem Solving domain of the ASQ in the whole sample. After stratifying by child sex, the positive association between CS and the Problem Solving domain was significant in boys, while no association was found in girls. Girls were rated less optimally in the Gross Motor domain of the ASQ when born via CS. Mode of birth was not associated with behavioral outcomes.

Correction to: One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma

An amendment to this paper has been published and can be accessed via the original article.

One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma {1}

Background

Severe perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour.

Methods/design

In this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18–47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1–2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women’s experiences, midwives’ experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women’s experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health.

Discussion

It is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women.

Trial registration {2a}

ClinicalTrials.gov NCT03770962. Registered on 10 December 2018

An ethnographic study of the interaction between philosophy of childbirth and place of birth

BACKGROUND

Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings.

AIM

To explore how childbirth is constructed and influenced by context in three birth settings in Australia.

METHOD

This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16).

RESULTS

All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident.

CONCLUSIONS

A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.

Birth models of care and intervention rates: The impact of birth centres

Birth centres offer a midwifery-led model of care which supports a non-medicalised approach to childbirth. They are often reported as having low rates of birth intervention, however the precise impact is obscured because less disadvantaged mothers with less complex pregnancies, and who prefer and often select little intervention, are more likely to choose a birth centre. In this paper, we use a methodology that purges the impact of these selection effects and provides a causal interpretation of the impact of birth centres on intervention outcomes. Using administrative birth data on over 364,000 births in Australia's most populous state between 2001 and 2012, we implement an instrumental variables framework to address confounding factors influencing choice of birth setting. We find that giving birth in a birth centre results in significantly lower probabilities of intervention, and that critically, this impact has been increasing over time. Our estimates are larger than those in existing studies, reflecting our newer data, diverging intervention rates across birth settings, and our accounting for important selection effects. The results emphasise the greater role of birth centres in delivering on policy priorities which include greater maternal autonomy, lower intervention rates, and lower health system costs.

The feasibility of acupuncture as an adjunct intervention for antenatal depression: a pragmatic randomised controlled trial

BACKGROUND

Antenatal depression is common and associated with adverse consequences for mothers, babies, and future generations. Limitations with conventional approaches has resulted in additional therapies being considered. This study examined the feasibility and effectiveness of acupuncture for improving mental health.

METHODS

Fifty-seven pregnant women with depressive symptomologies were randomised to acupuncture (n=19) plus treatment as usual (TAU), progressive muscle relaxation (PMR, n=19) plus TAU or TAU (n=19). Treatments were conducted from 24 to 31 weeks gestation. Clinical assessments were performed throughout the intervention, as well as at a six-week postnatal follow-up. The primary outcome measure was depression. Secondary outcome measurements were stress, anxiety, psychological distress, quality of life and adjustment to mothering. Intention to treat (ITT), Linear Mixed Model (LMM) repeated measures and per protocol (PP) analyses were conducted.

RESULTS

At end-of-intervention there were significantly lower depression scores in the acupuncture group versus TAU and PMR respectively [ITT p<0.001, mean difference (MD) -5.84 (95% CI -9.10 to -2.58); MD -3.42 (95% CI -6.64 to -0.20)]. LMM repeated measures analysis (including postnatal follow-up) also demonstrated significantly lowered acupuncture group scores for stress (p=0.006) and psychological distress (p<0.001) when compared to PMR and TAU. Between group differences were not significant at six-weeks postnatal. No adverse events were reported.

LIMITATIONS

Main limitations are small sample size and the use of self-reported outcome measures.

CONCLUSION

Prenatal acupuncture reduced depression, stress and distress, whilst also being well-tolerated and free from adverse events. Further research is warranted.

The AEDUCATE Collaboration. Comprehensive antenatal education birth preparation programmes to reduce the rates of caesarean section in nulliparous women. Protocol for an individual participant data prospective meta-analysis

INTRODUCTION

Rates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme? METHODS AND ANALYSIS: Population: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women's confidence through psychological preparation (positive mindset) and support their ability to birth without pain relief using evidence-based tools (tools and techniques). The intervention could occur in a hospital-based or community setting.Comparator: standard care alone in hospital-based maternity units.

OUTCOMES

Primary: CS.Secondary: epidural analgesia, mode of birth, perineal trauma, postpartum haemorrhage, newborn resuscitation, psychosocial well-being.Subgroup analysis: parity, model of care, maternal risk status, maternal education, maternal socio-economic status, intervention components.

STUDY DESIGN

An individual participant data (IPD) prospective meta-analysis (PMA) of randomised controlled trials, including cluster design. Each trial is conducted independently but share core protocol elements to contribute data to the PMA. Participating trials are deemed eligible for the PMA if their results are not yet known outside their Data Monitoring Committees.

ETHICS AND DISSEMINATION

Participants in the individual trials will consent to participation, with respective trials receiving ethical approval by their local Human Research Ethics Committees. Individual datasets remain the property of trialists, and can be published prior to the publication of final PMA results. The overall data for meta-analysis will be held, analysed and published by the collaborative group, led by the Cochrane PMA group.

TRIAL REGISTRATION NUMBER

CRD42020103857.

The impact of planning for COVID-19 on private practising midwives in Australia

Problem

The COVID-19 pandemic response has required planning for the safe provision of care. In Australia, privately practising midwives are an important group to consider as they often struggle for acceptance by the health system.

Background

There are around 200 Endorsed Midwives eligible to practice privately in Australia (privately practising midwives) who provide provide the full continuum of midwifery care.

Aim

To explore the experience of PPMs in relation to the response to planning for the COVID-19 pandemic.

Methods

An online survey was distributed through social media and personal networks to privately practising midwives in Australia in April 2020.

Results

One hundred and three privately practising midwives responded to the survey. The majority (82%) felt very, or well informed, though nearly half indicated they would value specifically tailored information especially from professional bodies. One third (35%) felt prepared regarding PPE but many lacked masks, gowns and gloves, hand sanitiser and disinfectant. Sixty four percent acquired PPE through social media community sharing sites, online orders, hardware stores or made masks. Sixty-eight percent of those with collaborative arrangements with local hospitals reported a lack of support and were unable to support women who needed transfer to hospital. The majority (93%) reported an increase in the number of enquiries relating to homebirth.

Conclusion

Privately practising midwives were resourceful, sought out information and were prepared. Support from the hospital sector was not always present. Lessons need to be learned especially in terms of integration, support, education and being included as part of the broader health system.