Women’s experience of continuity of midwifery care in North-Eastern Italy: A qualitative study.
Eur J Midwifery, 7: DOI: https://doi.org/10.18332/ejm/159358
Introduction: The establishment of a maternity path is often hampered by the fragmentation of care processes resulting in discontinuity of care. The interruption of continuity of care negatively affects the experience of maternity. The purpose of this research is to analyse the experience of women who get midwifery continuity of care from pregnancy till after childbirth.
Conclusions: From the perspective of prevention and protection of maternal and child health, in the short- and long-term, it becomes essential to focus on developing maternal competencies. This may be possible by implementing midwifery continuity of care pathways with an appropriate and flexible organizational system capable of responding to women’s needs throughout the maternity journey, even during periods of a health emergency.
Project20: maternity care mechanisms that improve access and engagement for women with social risk factors in the UK – a mixed-methods, realist evaluation.
BMJ Open, 13,e064291 doi:10.1136/bmjopen-2022-064291
Objectives: To evaluate how women access and engage with different models of maternity care, whether specialist models improve access and engagement for women with social risk factors, and if so, how?
Results: The number of social risk factors women were experiencing increased with deprivation score, with the most deprived more likely to receive a specialist model that provided continuity of care. Women attending hospital-based antenatal care were more likely to access maternity care late (risk ratio (RR) 2.51, 95% CI 1.33 to 4.70), less likely to have the recommended number of antenatal appointments (RR 0.61, 95% CI 0.38 to 0.99) and more likely to have over 15 appointments (RR 4.90, 95% CI 2.50 to 9.61) compared with community-based care. Women accessing standard care (RR 0.02, 95% CI 0.00 to 0.11) and black women (RR 0.02, 95% CI 0.00 to 0.11) were less likely to have appointments with a known healthcare professional compared with the specialist model. Qualitative data revealed mechanisms for improved access and engagement including self-referral, relational continuity with a small team of midwives, flexibility and situating services within deprived community settings.
Conclusion: Inequalities in access and engagement with maternity care appears to have been mitigated by the community-based specialist model that provided continuity of care. The findings enabled the refinement of a realist programme theory to inform those developing maternity services in line with current policy.
The impact of social media influencers on pregnancy, birth, and early parenting experiences: A systematic review.
Midwifery, 120: https://doi.org/10.1016/j.midw.2023.103623
Aim: To systematically review the literature to identify what is known about how following social media ‘influencers’ and ‘bloggers’ impacts pregnant and new parents’ experiences and decision-making.
Discussion: Social media influencers provide a network of peers amongst whom discussions, supportive behaviours, and information sharing take place. However, concern arises around the potential for combative interactions, the risk for transmission of misinformation, and the potential impacts of following influencers who are also qualified health professionals.
Conclusion: Existing research suggests that engaging with social media influencers can be both beneficial and harmful for pregnant and new parents. At the current time, it is unclear how exposure to the benefits or harm impacts personal experiences and decision-making.
Consent during labour and birth as observed by midwifery students: A mixed methods study.
Women and Birth, S1871-5192. https://doi.org/10.1016/j.wombi.2023.02.005
Background: While consent is an integral part of respectful maternity care, how this is obtained during labour and birth presents conflicting understandings between midwives’ and women’s experiences. Midwifery students are well placed to observe interactions between women and midwives during the consent process.
Aim: The purpose of this study was to explore the observations and experiences of final year midwifery students of how midwives obtain consent during labour and birth.
Discussion: The student’s accounts suggest that in many instances during labour and birth the principles of informed consent are not being applied consistently. Presenting interventions as routine care subverted choice for women in favour of the midwives’ preferences.
Conclusions: Consent during labour and birth is invalidated by a lack of disclosure of risks and alternatives. Health and education institutions should include information in guidelines, theoretical and practice training on minimum consent standards for specific procedures inclusive of risks and alternatives.
Support for healthy breastfeeding mothers with healthy term babies.
Cochrane Database of Systematic Reviews,10. DOI: 10.1002/14651858.CD001141.pub6
Background: There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant’s diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.
Authors’ conclusions: When ‘breastfeeding only’ support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points. For ‘breastfeeding plus’ interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face‐to‐face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.
Midwives and sexual violence: A cross-sectional analysis of personal exposure, education and attitudes in practice.
Women and Birth, 35(5):e487-e493.
Around one in three women experience sexual violence during their lifetime. They may need trauma-sensitive maternity care that takes sexual trauma triggers into account. Midwives are similarly likely to have experienced sexual violence in their lifetime. It is unknown whether midwives with a personal sexual violence history have a different professional approach to the topic than their colleagues without such history.
To explore whether midwives with a personal sexual violence history are more likely to have received or need education about sexual violence and whether they approach sexual violence differently in practice.
As fellow survivors, midwives with a personal sexual violence history have a unique standpoint towards sexual violence in maternity care practice that may make them more sensitive to the issue.
Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial.
Eur J Obstet Gynecol Reprod Biol X. 16:100165.
To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy
In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1% versus 1.9%) and severe adverse (0.3% versus 1.0%) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3,642 women. Caesarean section rates were comparable.
Experience of induction of labour: a cross-sectional postnatal survey of women at UK maternity units.
BMJ Yale medRxiv, doi: https://doi.org/10.1101/2022.11.30.22282928
Induction of Labour (IOL) is an increasingly common obstetric intervention, offered to 30-50% of pregnant women in the UK. IOL affects experience of childbirth: it is more painful than spontaneous labour and more likely to lead to additional interventions including operative birth. Experience of childbirth is important to women, and negative experience of childbirth has been linked to serious psychological harm. The high and rising rate of IOL has implications for provision of safe, effective, person-centred maternity services, yet there is little information about women’s experiences of induction.
To explore women’s views and experiences of key elements of the IOL process, including at home or in hospital cervical ripening (CR)
Women do not experience IOL as a benign and consequence free intervention. There is urgent need for research to better target IOL and optimise safety and experience for women and their babies. Relatively few women were offered CR at home and further research is needed on this experience.
First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined.
Front Nutr, 9: https://doi.org/10.3389/fnut.2022.1049610
In March 2020, the World Health Organization (WHO) published clinical guidance for the care of newborns of mothers with COVID-19. Weighing the available evidence on SARS-CoV-2 infection against the well-established harms of maternal-infant separation, the WHO recommended maternal-infant proximity and breastfeeding even in the presence of maternal infection. Since then, the WHO’s approach has been validated by further research. However, early in the pandemic there was poor global alignment with the WHO recommendations.
Conclusion: Despite the WHO recommendations, many COVID-19 maternal and newborn care guidelines failed to recommend skin-to-skin contact, rooming-in, and breastfeeding as the standard of care. Irregular guidance updates and the discordant, but influential, guidance from the United States Centers for Disease Control may have been contributory. It appeared that once recommendations were made for separation or against breastfeeding they were difficult to reverse. In the absence of quality evidence on necessity, recommendations against breastfeeding should not be made in disease epidemics.
Health and nutrition claims for infant formula: international cross sectional survey.
To review available health and nutrition claims for infant formula products in multiple countries and to evaluate the validity of the evidence used for substantiation of claims.
Most infant formula products had at least one health and nutrition claim. Multiple ingredients were claimed to achieve similar health or nutrition effects, multiple claims were made for the same ingredient type, most products did not provide scientific references to support claims, and referenced claims were not supported by robust clinical trial evidence.
Midwifery continuity of care: A scoping review of where, how, by whom and for whom?
PLOS Global Public Health, 2(10): e0000935
Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.
Predictors and impact of women’s breastfeeding self-efficacy and postnatal care in the context of a pandemic in Australia and Aotearoa New Zealand
To investigate predictors of breastfeeding self-efficacy, postnatal care experiences, and there subsequent impact on breastfeeding outcomes in Australia and Aotearoa New Zealand in the context of the COVID-19 pandemic.
There were 1001 complete responses. Visitor restrictions impacted the woman’s early parenting experience in both positive and negative ways. One third of participants stated their postnatal needs were not met with 82 stating that they had no postnatal care at all. During the first six weeks postnatal, 48.1% felt not very or not at all confident caring for their baby. Despite 94.3% of participants initiating breastfeeding, only 70% were exclusively breastfeeding at six weeks. The mean self-efficacy score was 49.98 suggesting the need for additional help, with first time mothers having a statistically significant lower score.
Sub-optimal postnatal care and support negatively influence breastfeeding self-efficacy. Women desired additional help during the COVID-19 pandemic inclusive of support and education to meet their postnatal needs and exclusively breastfeed.
Implications for practice
Women require appropriate and timely postnatal care and support to promote confidence in caring for baby and achieve their breastfeeding goals. Preferably this care should be provided face-to-face.
Antibodies in the breastmilk of COVID-19 recovered women
BMC Pregnancy and Childbirth 22, 635
Human milk contains antibodies against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) which may serve as a protective factor through passive immunization in infants. The objective of this study was to measure the levels of anti-SARS-CoV-2 IgG and IgA in human milk and serum after a SARS-CoV-2 infection.
Our results confirm the presence of SARS-CoV-2 IgA and IgG antibodies in the breastmilk of COVID-19 recovered women and the possibility of these antibodies in providing specific immunologic benefits to breastfeeding infants such as protection against the virus transmission and severity of the acquired COVID-19 disease.
Insider knowledge as a double-edged sword: an integrative review of midwives’ personal childbearing experience
BMC Pregnancy and Childbirth, 22, 640
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.
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.
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.
Tighter or less tight glycaemic targets for women with gestational diabetes mellitus for reducing maternal and perinatal morbidity: A stepped-wedge, cluster-randomised trial.
PLoS Med 19(9): e1004087. https://doi.org/10.1371/journal.pmed.1004087
Treatment for gestational diabetes mellitus (GDM) aims to reduce maternal hyperglycaemia. The TARGET Trial assessed whether tighter compared with less tight glycaemic control reduced maternal and perinatal morbidity.
Tighter glycaemic targets in women with GDM compared to less tight targets did not reduce the risk of a large for gestational age infant, but did reduce serious infant morbidity, although serious maternal morbidity was increased. These findings can be used to aid decisions on the glycaemic targets women with GDM should use.
How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis
Women Birth, 35(1):e1-e9. doi:10.1016/j.wombi.2021.01.012
A care bundle was introduced into 28 Australian hospitals in 2018 with the aim of reducing severe perineal tears. There has been limited research regarding the impact of this bundle on women’s birth experiences.
Three descriptive themes were generated: 1) Lack of information and consent to bundle elements, 2) Other non-consented and disrespectful treatment and 3) Recommendations for hospitals and clinicians. Two analytic themes were generated: 1) Default-position: Prioritising policies over women’s autonomy and 2) Counter-position: Women asserting their rights to autonomy and respect.
None of the women interviewed could recall having received information about the perineal care bundle from clinicians during pregnancy. While many women accepted that its elements were in their or their baby’s best interests, this was not the case for all women. Some women reported coercive and non-consented application of bundle elements, which they found distressing.
Given the broader institutional context in which the perineal bundle was implemented, the impact on information provision, informed consent and the detrimental emotional consequences for some women arising from the bundle’s implementation were largely foreseeable. The potential for bundled care initiatives to impinge on women’s human rights to autonomy and respectful care should be given greater preventative attention prior to implementation.
More home births during the COVID-19 pandemic in the Netherlands
The aim of this observational study was to examine whether the course of pregnancy and birth and accompanying outcomes among low-risk pregnant women changed in the COVID-19 pandemic compared to the prepandemic period.
We included 5913 low-risk pregnant women of whom 2963 (50.1%) were pregnant during the first surge of the COVID-19 pandemic, and 2950 (49.9%) in the prepandemic period. During the COVID-19 pandemic, more women desired and had a home birth. More women used pain medication and fewer had an episiotomy in the COVID-19 period than prior. Multiparous women had a higher suspected rate of fetal growth restriction during COVID; however, the actual rate of small for gestational age infants was not significantly increased. We observed no differences for onset and augmentation of labor or for mode of birth, though the rate of vaginal births increased.
During the COVID-19 pandemic, there was a higher rate of planned and actual home birth, and suspected growth restriction and a lower rate of episiotomy among low-risk pregnant women in the Netherlands.
Inducing labour in the United Kingdom: A feminist critical discourse analysis of policy and guidance.
SSM – Qualitative Research in Health, 2 – https://doi.org/10.1016/j.ssmqr.2022.100108
Induction of labour (IOL), the process of starting labour artificially, is one of the most commonly performed procedures in maternity care in the United Kingdom (UK), yet there is debate whether inducing labour at ‘term’, in the absence of specific medical indication, is beneficial and reduces risk of stillbirth. Moreover, rates of routine IOL are rapidly rising in the UK, despite uncertainty about the evidence base and parents reporting receiving a lack of balanced information about the process. As a contested area of maternity care, the language used to debate, describe and discuss IOL takes on added significance and requires in-depth examination and analysis. To address this, we conducted a feminist critical discourse analysis on policy and professional writing about IOL in the UK, focusing on how these both reflect and construct social practices of pregnancy and birth. Our analysis identified a double discourse about IOL, which we term ‘explicit-implicit discourse of care’, revealing the differences between what is expected to be said and what is really said. Though most texts displayed an explicit discourse of care, which espoused women-centred care and informed choice, they also conveyed an implicit discourse of care, primarily composed of three key dimensions: women as absent actors, disembodiment, and evidence as a primary actor. We argue that this explicit-implicit discourse functions to preserve healthcare professionals’ control over maternity care and further alienate women from their own bodies while maintaining a discursive position of women-centred care and informed choice.
Cord clamping beyond 3 minutes: Neonatal short‐term outcomes and maternal postpartum hemorrhage.
Delaying cord clamping (CC) for 3-5 minutes reduces iron deficiency and improves neurodevelopment. Data on the effects of CC beyond 3 minutes in relation to short-term neonatal outcomes and maternal risk of postpartum hemorrhage are scarce.
Umbilical CC times beyond 3 minutes in vaginal deliveries were not associated with negative short-term outcomes in newborns and were associated with a smaller maternal postpartum blood loss. Although CC time as long as 6 minutes could be considered as safe, further research is needed to decide the optimal timing.
Birth plans: A systematic, integrative review into their purpose, process, and impact.
Midwifery, 111:103388 – doi: 10.1016/j.midw.2022.103388
The birth plan was introduced in the 1980s to facilitate communication between maternity care providers and women and increase agency for childbearing women in the face of medicalised birth. Forty years on, the birth plan is a heterogeneous document with uncertainty surrounding its purpose, process, and impact. The aim of this review was to synthesise the evidence and improve understanding of the purpose, process and impact of the birth plan on childbearing women’s experiences and outcomes.
Despite the heterogeneity of birth plans, birth plans were associated with positive outcomes for childbearing women when developed in collaboration with care providers. The act of collaboratively creating a birth plan may improve obstetric outcomes, aid realistic expectations, and improve satisfaction and the sense of control.
Maternal and neonatal outcomes of women with gestational diabetes and without specific medical conditions: an Australian population-based study comparing induction of labor with expectant management.
Aust NZ J Obstet Gynaecol,1-11. https://doi.org/10.1111/ajo.13505
To evaluate maternal birth and neonatal outcomes among women with gestational diabetes mellitus (GDM), but without specific medical conditions and eligible for vaginal birth who underwent induction of labour (IOL) at term compared with those who were expectantly managed.
In women with GDM but without specific medical conditions and eligible for vaginal birth, IOL at 38, 39, 40 weeks gestation is associated with an increased risk of caesarean section.
“Never let a good crisis go to waste”: Positives from disrupted maternity care in Australia during COVID-19.
Midwifery, 110(103340): https://doi.org/10.1016/j.midw.2022.103340
Due to the COVID-19 pandemic, a number of changes to maternity care were rapidly introduced in all countries, including Australia, to reduce the risk of infection for pregnant women and their care providers. While many studies have reported on the negative effects of these changes, there is a paucity of evidence on factors which women and their providers perceived as positive and useful for future maternity care.
Despite the negative effect of COVID-19-related restrictions on maternity care, a variety of changes were viewed as positive by both women and midwives, with strong agreement between the two groups.
Implications for practice
These findings provide evidence to support the inclusion of these positive elements of care and ensure that the lessons learned from the pandemic are utilised to improve maternity care in Australia going forward.
Kangaroo mother care had a protective effect on the volume of brain structures in young adults born preterm.
Acta Paediatrica, 11(5): 1004-1014.
The protective effects of Kangaroo mother care (KMC) on the neurodevelopment of preterm infants are well established, but we do not know whether the benefits persist beyond infancy. Our aim was to determine whether providing KMC in infancy affected brain volumes in young adulthood.
Our findings suggest that the neuroprotective effects of KMC for preterm infants persisted beyond childhood and improved their lifetime functionality and quality of life.
Breastfeeding Is Associated With a Reduced Maternal Cardiovascular Risk: Systematic Review and Meta‐Analysis Involving Data From 8 Studies and 1 192 700 Parous Women.
Journal of the American Heart Association, 11(2) – https://doi.org/10.1161/JAHA.121.022746
Breastfeeding has been robustly linked to reduced maternal risk of breast cancer, ovarian cancer, and type 2 diabetes. We herein systematically reviewed the published evidence on the association of breastfeeding with maternal risk of cardiovascular disease (CVD) outcomes.
Breastfeeding was associated with reduced maternal risk of CVD outcomes.
A comparison of the Woman-centred care: strategic directions for Australian maternity services (2019) national strategy with other international maternity plans.
Women and Birth, https://doi.org/10.1016/j.wombi.2022.04.003
In 2019 the Australian government released a guiding document for maternity care: Woman-centred care strategic directions for Australian maternity services (WCC Strategy), with mixed responses from providers and consumers. The aims of this paper were to: examine reasons behind reported dissatisfaction, and compare the WCC Strategy against similar international strategies/plans. The four guiding values in the WCC strategy: safety, respect, choice, and access were used to facilitate comparisons and provide recommendations to governments/health services enacting the plan.
Maternity strategy/plans should be based on the best available evidence, with consistent and complementary recommendations. Within this framework, priority should be given to women’s preferences and choices, rather than the interests of organisations and individuals