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Access to water immersion for labour and birth during the pandemic: an opinion piece

During the final year of the Bachelor of Midwifery at Griffith University, midwifery students are asked to write an opinion piece focussed on normal birth that could be published. Dr Jyai Allen convenes this course and supported the students to complete this work. Several of these were of such good quality that we offered students the option of having them published here. This is the first of four articles in a series. The author of this article preferred to publish anonymously. 

Access to water immersion for labour and birth during the pandemic: an opinion piece

There is no denying that COVID-19 has completely changed the world (United Nations Children’s Fund, 2020). Many populations have been unequally disadvantaged by the global pandemic, including childbearing women (Gausman & Langer, 2020). It has been a period of heightened anxiety as new policies aimed at flattening the curve have limited women’s birth preferences and choices (Australian College of Midwives [ACM], 2020a). This includes the Royal Australian and New Zealand College of Obstetrics and Gynecology (RANZCOG) recommendation to suspend the use of water immersion for all labouring women within COVID-19 hotspots (ACM, 2020a). Whilst staunchly opposed by ACM (2020a), this position statement has been adopted by health services across the nation including the Department of Health and Human Services [DHHS] in Victoria (2020). The topic is controversial as the suspension of access to water immersion is not supported by evidence (Centres for Disease Control [CDC], 2020a) and devalues a woman’s autonomy and right to self-determination.

Midwives have a professional obligation to advocate for evidence-based practices that empower women and promote normal birth. Water immersion during labour is associated with positive outcomes and should be available to all low-risk women who are presumed or confirmed COVID-19 negative.

Arguments for the suspension

Let us consider the evidence for suspending water immersion in the context of a woman with a confirmed positive COVID-19 test result. The rationale behind RANZCOGs recommendation was the protection of healthcare workers (ACM, 2020a; 2020b). Concerns have been raised regarding the level of protection provided by personal protective equipment when immersed in water (DHHS, 2020; Royal College of Midwives [RCM], 2020). It was also believed the moist atmosphere of the birth pool room could increase the risk of droplet transmission (RCM, 2020).

Some evidence contradicts this viewpoint, however, finding the virus is less likely to be transmitted in humid environments (Qi et al., 2020). Given that COVID-19 is not a waterborne virus, it is believed that liquid may dilute contamination and therefore reduce the potential risk of transmission (ACM, 2020a). Another potential benefit from water immersion is that the birth pool aids in physical distancing by providing a barrier between women and care providers (Burns et al., 2020; Ulfsdottir et al., 2018).

Another concern that was raised was faecal-oral transmission of COVID-19 within a birth pool. While some studies suggest the virus can be transmitted through faeces (Wang et al., 2020; Zhang et al., 2020a), there has been no evidence of faecal-oral transmission to date (World Health Organization, 2020). Some argued that if faeces were highly contagious for COVID-19, healthcare workers would be at greater risk during land birth as the particles are not diluted (ACM, 2020a). So while water immersion has been framed as posing a risk to clinical staff, women and babies; there is limited evidence to suggest it is easily spread to humans through birth pools (CDC, 2020a).

Benefits of water immersion

It is important to recognise the known benefits of water immersion during labour and for birth. Water immersion facilitates positive birth experiences (Cooper & Warland, 2019; Lathrop et al., 2018; Neiman et al., 2019). When immersed in water during labour, women have increased feelings of empowerment and experience a greater sense of privacy, safety, control and focus (Fair et al., 2020; Ulfsdottir et al., 2018). It is also an effective pain management method which can help to avoid a cascade of intervention and therefore promotes normal birth practices (Cluett et al., 2018). Women who were prevented from accessing water immersion as a consequence of their COVID-19 status would not access these benefits. The arbitrary decision to suspend water immersion for all labouring women is consistent with historical practices in maternity care that value subjectivity over evidence-based recommendations (Cooper et al., 2017).

What the suspension really represents

It can be assumed that broader socio-cultural factors have influenced RANZCOGs recommendation. RANZCOG is an obstetric organisation that aligns itself with the technocratic model of care and values surveillance, intervention, and hierarchy (Davis-Floyd, 2001). This is demonstrated by their staunch and public opposition to practices such as homebirth – which is discussed in the context of obstetric outcomes and perinatal mortality (Licqurish & Evans, 2015).

RANZCOGs position statement on water immersion is similar. By standardising institutional practices and banning all women from using water immersion, the individual needs of women are deemed unimportant. Consequently, these clinicians retain their position at the top of the organisation’s hierarchy (Davis-Floyd, 2001). The recommendation represents authority and responsibility inherent in the healthcare provider, not the woman –  as the woman’s personal preferences are disregarded by the institution (Davis-Floyd, 2001).

Loss of choice and failing to make decisions in partnership with women may also add to women’s feelings of stress and anxiety (Jago et al., 2020). This further impacts normal birth outcomes as women are passive in decision-making and do not challenge recommended practices (Carolan- Olah et al., 2015). The prohibition of water immersion also fails to demonstrate a holistic approach to care as the social and emotional needs of women are neglected (Jago et al., 2020) during a period in history that has elevated anxiety and depression amongst pregnant women (Lebel et al., 2020).

Medicalisation of childbirth also likely influenced the decision to suspend water immersion. An obstetric approach views water immersion as inherently risky and therefore requires medical management (Licqurish & Evans, 2016; Milosevic et al., 2019). This is demonstrated by RANZCOGs recommendations for water immersion statement (2017) which focuses on rigorous protocols, exclusion criteria, and obstetric emergency drills. Their value of a medicalised approach is also apparent when considering that they have not recommended suspending the use of nitrous oxide for all labouring women (RANZCOG, 2020c), despite posing a higher risk of contracting COVID-19 through droplet or aerosol transmission (ACM, 2020a; CDC, 2020b).

The influence of medicalisation is even more obvious in the recommendation to site an epidural early in labour, in case an emergency caesarean section becomes ‘indicated’ (DHHS, 2020). This practice has been adopted by Barwon Health, along with the recommendation of continuous fetal heart rate monitoring, should a woman be suspected of COVID-19 (2020). Normal birth outcomes then become even more difficult to achieve as interventions such as instrumental birth are increased (Alfirevic et al., 2017).

To affect any sort of change, it is important for midwives to gain confidence in water immersion (Plint & Davis, 2016). Lack of training creates a workplace culture where water immersion is feared (Klein et al., 2011). Consequently, medicalised approaches are promoted as midwives do not feel confident advocating for normal birth practices.

The media also plays a pivotal role in the depiction of childbirth, often shaping public opinion irrespective of evidence (Petrovska et al., 2017). Normal birth practices are vastly underrepresented, with childbirth often portrayed as medicalised and risky (Luce et al., 2016). Commonly associated with fear, pain and intervention, high-impact dramatic stories are more often depicted in the media rather than calm, normal births (Maclean, 2014). Media portrayals will influence women’s perceptions of water immersion given that two out of three women source information from the media instead of their healthcare provider (Carlsson & Ulfsdottir, 2020). Combined with media coverage on COVID-19, it is no wonder water immersion is scarcely supported. As women become fearful of childbirth, they are disempowered to advocate for normal birth practices (Plint & Davis, 2020). It is imperative for midwives to support women in making informed choices to ensure their decisions are not influenced by fear perpetuated by the media
(Jago et al., 2020).

How do we move forward?

Maintaining the health and safety of women, babies, and healthcare workers is paramount.

Measures can be taken to minimise the potential risk of COVID-19 transmission whilst still promoting normal birth practices. Screening women for COVID-19 and fast-track testing will inform care management more accurately (RCM, 2020). Individualised risk assessments should be undertaken and midwives should demonstrate effective clinical decision making (RCM, 2020). Being up-to-date with infection control practices would be supportive (Liang & Archarya, 2020; Public Health England, 2020) along with access to appropriate personal protective equipment (RCM, 2020). Burns et al. (2020) found wearing long gauntlet gloves that are one size too small can improve the seal when immersed in water. Maintaining proper cleaning and hygiene practices reduces the risk of transmission (ACM, 2020a) as well as removing faecal matter should it contaminate the water (Gu et al., 2020).

Empowering women to guide their babies into the world while immersed in water facilitates physical distancing practices (RCM, 2020). This would be supported by antenatal education as it  instills confidence and allows women to engage in their care (ACM, 2020a; Milosevic et al., 2019; Plint & Davis, 2016). Arguably the most important factor, is that midwives must be trained in water immersion. This will ensure competence and develop a workplace culture that supports normal birth practices (Nicholls et al., 2016). Midwives should also engage in respectful conversations that promote midwifery care by challenging practices that are deemed unnecessary or not based on evidence.

In summary

Midwives have a professional obligation to protect choices for women and promote normal birth practices (ACM, 2020b). Water immersion should be available to all women. RANZCOGs recommendation is not based on evidence and has been influenced by technocratic ideologies. As gatekeepers to normal birth, midwives are in a powerful position to influence maternity reform and must continually advocate for evidence-based practices to ensure women are supported throughout their childbearing journey (McIntyre et al., 2012).

References

Alfirevic, Z., Gyte, G., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, (5), 1-141. https://dx.doi.org/10.1002/14651858.CD006066.pub3

Australian College of Midwives. (2020a). ACM’s updated position on use of water in labour. https://www.midwives.org.au/news/acm-s-updated-position-use-water-labour

Australian College of Midwives. (2020b). Midwifery philosophy and values. https://www.midwives.org.au/midwifery-philosophy-values

Barwon Health. (2020). COVID-19 (coronavirus) and pregnancy.
https://www.barwonhealth.org.au/maternity-services/component/zoo/item/covid-19- coronavirus-and-pregnancy

Burns, E., Cooper, M., Feeley, C., Hall, P., Roehr, C., & Venderlaan. (2020). Coronavirus COVID-19: Supporting healthy pregnant women to safely give birth. https://www.brookes.ac.uk/WorkArea/DownloadAsset.aspx?id=2147622699

Carlsson, T., & Ulfsdottir, H. (2020). Waterbirth in low‐risk pregnancy: An exploration of women’s experiences. Journal of Advanced Nursing, 76(5), 1221-1231. https://dx.doi.org/10.1111/jan.14336

Carolan-Olah, M., Kruger, G., & Garvey-Graham, A. (2015). Midwives׳ experiences of the factors that facilitate normal birth among low risk women at a public hospital in Australia. Midwifery, 31(1), 112-121. https://dx.doi.org/10.1016/j.midw.2014.07.003

Center for Disease Control. (2020a). Coronavirus Disease 2019 (COVID-19) [Topic: Pools, Hot Tubs, and Water Playgrounds]. https://www.cdc.gov/coronavirus/2019- ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2 019-ncov%2Fphp%2Fwater.html#COVID-19-and-Water

Center for Disease Control. (2020b). How COVID-19 Spreads. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid- spreads.html

Cluett, E., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. Cochrane Database of Systematic Reviews, (6), 1-171. https://dx.doi.org/10.1002/14651858.cd000111.pub4

Cooper, M., McCutcheon, H., & Warland, J. (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, 30(5), 431-441. https://dx.doi.org/10.1016/j.wombi.2017.04.001

Cooper, M., & Warland, J. (2019). What are the benefits? Are they concerned? Women’s experiences of water immersion for labor and birth. Midwifery, 79, 102541-102551. https://dx.doi.org/10.1016/j.midw.2019.102541

Davis-Floyd, R. (2001). The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology and Obstetrics, 75(1), 5-23. https://dx.doi.org/10.1016/S0020-7292(01)00510-0

Department of Health and Human Services. (2020). Maternity and neonatal care during coronavirus (COVID-19). https://www.dhhs.vic.gov.au/covid-19-maternity-and-neonatal- care-during-coronavirus

Fair, C., Crawford, A., Houpt, B., & Latham, V. (2020). “After having a waterbirth, I feel like it’s the only way people should deliver babies”: The decision-making process of women who plan a waterbirth. Midwifery, 82, 102622-102628. https://dx.doi.org/10.1016/j.midw.2019.102622

Gausman, J., & Langer, A. (2020). Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health, 29(4), 465–466. https://dx.doi.org/10.1089/jwh.2020.8472

Gu, J., Han, B., & Wang, J. (2020). COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology, 158(6), 518-519. https://dx.doi.org/10.1053/j.gastro.2020.02.054

Jago, C., Singh, S., & Moretti, F. (2020). Coronavirus disease 2019 (COVID-19) and pregnancy: Combating isolation to improve outcomes. Obstetrics and Gynecology, 136(1), 33-36. https://dx.doi.org/10.1097/AOG.0000000000003946

Klein, M., Liston, R., Fraser, W., Baradaran, N., Hearps, S., Tomkinson, J., Kaczorowski, J., & Brant, R. (2011). Attitudes of the new generation of Canadian obstetricians: How do they differ from their predecessors? Birth, 38(2), 129-139. https://dx.doi.org/10.1111/j.1523- 536x.2010.00462.x

Lathrop, A., Bonsack, C., & Haas, D. (2018). Women’s experiences with water birth: A matched groups prospective study. Birth, 45(4), 416-423. https://dx.doi.org/10.1111/birt.12362

Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020). Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic. Journal of Affective Disorders, 277, 5-13. https://dx.doi.org/10.1016/j.jad.2020.07.126

Liang, H., & Acharya, G. (2020). Novel coronavirus disease (COVID‐19) in pregnancy: What clinical recommendations to follow? Acta Obstetricia et Gynecologica Scandinavica, 99(4), 439-442. https://dx.doi.org/10.1111/aogs.13836

Licqurish, S., & Evans, A. (2016). ‘Risk or Right’: A discourse analysis of midwifery and obstetric colleges’ homebirth position statements. Nursing Inquiry, 23(1), 86-94. https://dx.doi.org/10.1111/nin.12111

Luce, A., Cash, M., Hundley, V., Cheyne, H., van Teijlingen, E., & Angell, C. (2016). “Is it realistic?” the portrayal of pregnancy and childbirth in the media. BMC Pregnancy and Childbirth, 16(1), 40. https://dx.doi.org/10.1186/s12884-016-0827-x

Maclean, E. (2014). What to expect when you’re expecting? Representations of birth in British newspapers. British Journal of Midwifery, 22(8), 580-588. https://dx.doi.org/10.12968/bjom.2014.22.8.580

McIntyre, M., Francis, K., & Chapsman, Y. (2012). Primary maternity care reform: Whose influence is driving the change?. Midwifery, 28(5), 705-711. https://dx.doi.org/10.1016/j.midw.2011.08.004

Milosevic, S., Channon, S., Hunter, B., Nolan, M., Hughes, J., Barlow, C., Milton, R., & Sanders, J. (2019). Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff. Midwifery, 79, 102554-102561. https://dx.doi.org/10.1016/j.midw.2019.102554

Neiman, E., Austin, E., Tan, A., Anderson, C., & Chipps, E. (2019). Outcomes of waterbirth in a US hospital‐based midwifery practice: A retrospective cohort study of water immersion during labor and birth. Journal of Midwifery & Women’s Health, 65(2), 216-223. https://dx.doi.org/10.1111/jmwh.13033

Nicholls, S., Hauck, Y., Bayes, S., & Butt, J. (2016). Exploring midwives’ perception of confidence around facilitating water birth in Western Australia: A qualitative descriptive study. Midwifery, 33, 73-81. https://dx.doi.org/10.1016/j.midw.2015.10.010

Petrovska, K., Sheehan, A., & Homer, C. (2017). Media representations of breech birth: A prospective analysis of web‐based news reports. Journal of Midwifery & Women’s Health, 62(4), 434-441. https://dx.doi.org/10.1111/jmwh.12609

Plint, E., & Davis, D. (2016). Sink or Swim: Water immersion for labor and birth in a tertiary maternity unit in Australia. International Journal of Childbirth, 6(4), 206-222. https://dx.doi.org/10.1891/2156-5287.6.4.206

Public Health England. (2020). COVID-19: infection prevention control guidance. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection- prevention-and-control

Qi, H., Xiao, S., Shi, R., Ward, M., Chen, Y., Tu, W., Su, Q., Wang, W., Wang, X., & Zhang, Z. (2020). COVID-19 transmission in Mainland China is associated with temperature and humidity: A time-series analysis. Science of the Total Environment, 728, 138778. https://dx.doi.org/10.1016/j.scitotenv.2020.138778

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2017). Warm water immersion during labour and birth. https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical- Obstetrics/Warm-water-immersion-during-labour-and-birth-(C-Obs-24)-Review-July- 2017.pdf?ext=.pdf

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020a). COVID-19: Protection of midwives and doctors in the birth unit. https://ranzcog.edu.au/news/covid-19-protection-of-midwives-and-doctors-in-th

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020b). RANZCOG statement. https://ranzcog.edu.au/news/ranzcog-statement

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2020c). A message for pregnant women and their families. https://ranzcog.edu.au/statements- guidelines/covid-19-statement/information-for-pregnant-women

Royal College of Midwives. (2020). RCM Professional briefing on waterbirths for women without symptoms during the COVID-19 pandemic. https://www.rcm.org.uk/media/4034/rcm-professional-briefing-on-waterbirth-in-the- time-of-covid-v-3-7-may-2020.pdf

Ulfsdottir, H., Saltvedt, S., Ekborn, M., & Georgsson, S. (2018). Like an empowering micro- home: A qualitative study of women’s experience of giving birth in water. Midwifery, 67, 26-31. https://dx.doi.org/10.1016/j.midw.2018.09.004

United Nations Children’s Fund. (2020). How COVID-19 is changing the world. https://data.unicef.org/resources/how-covid-19-is-changing-the-world-a-statistical-perspective/#

Wang, J., Tang, K., Feng, K.,; Li, X., Lv, W., Chen, K., & Wang, F. (2020). High temperature and high humidity reduce the transmission of COVID-19. Centre for Evidence- Based Medicine. https://www.cebm.net/study/covid-19-high-temperature-and-high- humidity-reduce-the-transmission-of-covid-19/

World Health Organization. (2020). Modes of transmission of virus causing COVID-19: Implications for IPC precautions and recommendations. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus- causing-covid-19-implications-for-ipc-precaution-recommendations

Zhang, Y., Chen,C., Zhu, S., Shu, C., Wang, D., Song, J., Song, Y., Zhen, W., Feng, Z., Wu, G., Xu, J., & Xu, W. (2020). Isolation of 2019-nCoV from a stool specimen of a laboratory- confirmed case of the coronavirus disease 2019 (COVID-19). China CDC Weekly, 2(8), 123-124. http://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2020.033

Does intrapartum CTG monitoring save lives?

Dr Kirsten Small is a project lead with the Transforming Maternity Care Collaborative. Yesterday she delivered the closing keynote address at the GOLD Obstetric Conference, speaking about why it is so difficult to align clinical practice with the research evidence. Kirsten hosts the Birth Small Talk blog and her post today reviews the research evidence she summarised in her address. She has kindly shared it here as well. 

If you are interested in pursuing research relating to the use of fetal heart rate monitoring in labour please connect with us via our contact form

 

Today’s post examines the research evidence about CTG monitoring with regards to stillbirth and neonatal death. This is a deep dive for my fellow data geeks who like to read the fine print, not the executive summary. The short version is – no. Using a CTG to monitor a woman in labour doesn’t prevent the death of her baby. If you are keen to know the details, read on!

Intrapartum CTG monitoring in low risk populations

This is the least controversial area of evidence, and the one most maternity clinicians are familiar with. Of the eleven randomised controlled trials that have compared CTG monitoring with intermittent auscultation (IA) during labour, three were done in low risk populations, five in high risk populations and the remaining three in mixed risk populations or where risk was not specified (Alfirevic et al., 2017).

The three low risk trials were Kelso et al., 1978, Leveno et al., 1986 and Wood et al., 1981. A total of 16,049 births were included in this analysis, which showed no statistically significant difference in the perinatal mortality rate (RR 0.87, 95% CI 0.29 – 2.58).

It has been almost 40 years since the last of these trials was performed. It could be argued that CTG technology has improved, or that we are better at CTG interpretation now. Heelan-Fancher et al. (2019) examined a large population data set from two states in the United States, specifically looking at birth outcomes for low risk women. This was not a randomised controlled trial – rather it was a non-experimental analysis of what happens in practice when women are monitored by CTG or by IA, with a very large sample size (1.5 million births). They didn’t report on intrapartum stillbirth. They found no significant difference in the neonatal mortality rate when CTG monitoring was used.

On the basis of available evidence, there is nothing that suggests that use of CTG monitoring rather than IA reduces the perinatal mortality rate in women considered to be at low risk. That’s not all that controversial. Most people in maternity care know this particular bit of information.

Intrapartum CTG monitoring in mixed, unknown, and high-risk populations

There is a widespread assumption that the absence of mortality benefit derived from CTG monitoring in labour ONLY applies to women considered to be low risk. We wouldn’t be using CTGs so widely if they didn’t save lives, right? But what does the evidence actually say regarding the use of intrapartum CTG monitoring in women who are not at low risk?

The randomised controlled trial evidence regarding high risk populations consists of five studies published over 6 papers, over a thirty-year period, starting in 1976 and continuing to 2006 (Haverkamp et al., 1979; Haverkamp et al., 1976; Luthy et al., 1987; Madaan and Trivedi, 2006; Renou et al., 1976; Shy et al., 1987). In addition, there are four studies published over five papers which were conducted in populations with both women considered to be at lower and higher risk or where the risk profile of the population was not described (Grant et al., 1989; Kelso et al., 1978; MacDonald et al., 1985; Neldam et al., 1986; Vintzileos et al., 1993). With my co-authors Associate Professor Mary Sidebotham, Professor Jenny Gamble, and Professor Jennifer Fenwick, we have synthesised the findings from these populations (Small et al., 2020).

In the high-risk population (n = 1,975), perinatal mortality was not significantly different when CTG was compared with IA (RR 1.17, 95% CI 0.62 – 2.22). There was also no statistically significant difference in mortality in the mixed-risk population (n = 15,994, RR 0.67, 95% CI 0.36 – 1.23). The mortality rate was higher in the mixed risk population than it was for the low risk population, and higher again for the high-risk population, indicating that researchers have correctly identified populations of women with higher risk.

Note that the number of women in the high-risk population is small. It has been argued that with a larger sample size a difference would be detected but that it would be unethical to recruit women considered to be a high-risk to further RCTs because the non-experimental evidence supporting the use of intrapartum CTG monitoring is so compelling. We set out to examine this assertion and examined the nonexperimental evidence (Small et al., 2020).

Non-experimental research

Our searches located 27 papers published between 1972 and 2018 which provided evidence about the use of intrapartum CTG monitoring in high-risk populations. We then used a tool (ROBINS-I) to assess the degree to which the findings of the research might be affected by bias – that is that the findings were due to something other than CTG use. 22 papers were at critical risk of bias and another was a serious risk. Most of these papers compared a time period prior to the introduction of CTG monitoring with a period after it was introduced, without controlling for any of the other changes to practice which might improve outcomes over time. Given the high risk of bias, the findings from these papers should not be relied on to guide practice as a consequence. The remaining five studies were assessed to be at moderate risk of bias. According to the ROBINS-I tool, studies at moderate risk of bias can be relied upon to inform clinical practice.

Starting with the studies at critical or serious risk of bias, only five of these studies showed a statistically significant reduction in perinatal mortality out of fourteen where this could be calculated. In the studies at moderate risk of bias (which ranged in size from 235 to 1.2 million women), no significant differences in perinatal mortality rates were reported. The argument that the non-experimental evidence presents a compelling argument for intrapartum CTG monitoring can’t be sustained on the basis of the available evidence.

Where to next?

Where does that leave us as clinicians and what recommendations can we make on the basis of these findings? We have an ethical obligation to include information regarding the lack of effectiveness of CTG monitoring in our discussions about intrapartum fetal monitoring with birthing women, regardless of their risk profile (Sartwelle et al., 2020) and to support their informed decision making. However, doing currently places clinicians at odds with professional guidelines. Professional guidelines are meant to be evidence informed, yet this is clearly not the case for intrapartum fetal monitoring. In order to support clinicians to provide evidence-informed care, there needs to be stronger recognition in professional guidelines that the evidence in favour of intrapartum CTG monitoring is far from compelling and that using IA instead is not proof of unprofessional practice.

The full reference list is available on the post on Birth Small Talk. 

 

Midwives’ mental health during the COVID19 pandemic

Identifying as a midwife is a source of joy and purpose for most midwives, but many midwives describe their midwifery work as challenging. Researchers from the Transforming Maternity Care Collaborative have been co-ordinating the Work, Health, and Emotional Lives of Midwives (WHELM) project. The project has identified high levels of burnout, depression, anxiety, and stress in Australian midwives (Creedy, et al., 2017) and also internationally (Cull, et al., 2020; Dixon, et al., 2017, Pezaro, et al., 2016, Stoll & Gallagher, 2019). Many midwives with high levels of burnout planned to leave midwifery practice, creating the potential for a significant shortfall in the number of qualified midwives available to provide safe maternity care.

This research was conducted prior to the arrival of the novel coronavirus pandemic that has transformed the maternity care workplace. Concerns have been raised regarding the potential for the pandemic to have a significant impact on the mental wellbeing of health professionals (Pfefferbaum & North, 2020). Recent research has shown high levels of anxiety among doctors, midwives, and nurses working in maternity services (Uzun, et al., 2020). Rapid and significant changes to the workplace have been required, particularly in places with large numbers of cases. Whether there will be further waves of infection is unpredictable. It is therefore highly likely that midwives’ emotional coping resources are under pressure.

It is important that we continue to measure the emotional health of midwives. To do that we need tools which are fit for purpose and have been used previously so there is a secure baseline to measure against. The WHELM team have developed, tested, and deployed such tools for a number of years (Pallant, et al., 2015; 2016), and are therefore well placed to provide advice this area.

Previous research from the WHELM consortium has demonstrated that a key protector of midwives’ mental wellbeing is working in a midwifery continuity of carer model (Sidhu, et al., 2020). Prioritising a shift away from traditional, fragmented models of maternity care to midwifery continuity of care is likely to enhance the sustainability of maternity care services through this and any future significant external challenges.

You can access the most recent paper from the WHELM consortium for free for a limited time – here.

References

Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth, 17, 13.

Cull, Hunter, Henley, Fenwick, Sidebotham. (2020). “Overwhelmed and out of my depth”: Responses from early career midwives in the United Kingdom to the Work, Health and Emotional Lives of Midwives study. Women and Birth, 33(6), e549-557.

Dixon,L., Guilliland,K., Pallant,J., Gilkison,A., Sidebotham,M., Fenwick,J.,McAra-Couper,J. (2017).The emotional wellbeing of New Zealand midwives: comparing responses between employed, self-employed (case loading) and midwives who do both. New Zealand College of Midwives Journal, 53, 5-14

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2015). Further validation of the Perceptions of Empowerment in Midwifery Scale. Midwifery, 31(10), 941– 945.

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2016). Adaptation and psychometric testing of the Practice Environment Scale for use with midwives. Women and Birth, 29(1), 24– 29.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. A., & Gerada, C. (2016). ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth, 29(3), e59– 66.

Pfefferbaum, B., & North, C.S. (2020). Mental health and the Covid-19 pandemic. New England Journal of Medicine, in press. https://doi.org/10.1056/NEJMp2008017

Sidhu R, Su B, Shapiro K & Stoll K. (2020). Exploring prevalence of and factors associated with Burnout in Midwifery: A Scoping Review. European Journal of Midwifery, 4(February), 4.

Stoll K & Gallagher J. (2019). A survey of burnout and intentions to leave the profession among Western Canadian midwives. Women and Birth, 32(4): e441-e449.

Uzun, N, Teki̇n, M, Sertel, E, Tuncar, A. (2020). Psychological and social effects of COVID-19 pandemic on obstetrics and gynecology employees. Journal of Surgery and Medicine, 4(5), 355-358. DOI: 10.28982/josam.735384

Red flags and gut feelings: midwives’ perceptions of screening for domestic and family violence

Domestic and family violence is significant problem affecting women in all countries. Defined as physical, sexual, or psychological harm at the hands of a current or former partner, domestic and family violence is the most common reason for hospital admission of women aged 15 – 54 years in Australia. Violence can begin for the first time in pregnancy or if already occurring, the frequency and intensity of violence can escalate. Midwives play an important role in helping women to recognise that they are experiencing domestic and family violence and linking women to appropriate support services to reduce the risk of serious harm.

A team of Transforming Maternity Care Collaborative researchers, led by Associate Professor Kathleen Baird, have recently published new research in this area (Baird, et al., 2020). Their research set out to explore midwives’ experiences in relation to screening for domestic and family violence.

Ten midwives, all with experience of working with women experiencing violence during pregnancy were interviewed. Key findings from the research were:
• Midwives valued ongoing training about working with women experiencing domestic and family violence,
• Midwives felt uncertain or unprepared to deal with domestic and family violence even after training and recognised that developing hands on experience is important,
• Midwives were reluctant to screen if they were not confident about what to do when a woman discloses a history of violence,
• Midwives described recognising “red flags” or having a “gut feeling” that something wasn’t right for some women who did not disclose a history of violence on routine questioning, and
• Having strong interpersonal relationships with women removed barriers to disclosure.

The authors concluded that “the best way to determine if the woman requires support is simply to ask her. However, it is important that this work with women is carried out in a supportive environment by a knowledgeable and trained midwife.”

References
Baird, K., Brandjerporn, G., Gillespie, K., Callander, E.J., & Creedy, DK. (2020). Red flags and gut feelings – midwives’ perceptions of domestic and family violence screening and detection in a maternity department. Women & Birth, in press.

How well does midwifery education prepare graduates to work in continuity of care models?

Access to continuity of midwifery care (CoMC) models in Australia is increasing but the capacity of the emerging midwifery workforce to provide this care remains largely unknown. Continuity of midwifery care has been a required component of Australian midwifery education programs since 2009 (ANMAC, 2009). This has been primarily achieved through the concept of the ‘Continuity of Care Experience’ (COCE), where midwifery students follow a woman on her journey through the pregnancy, birth, and postnatal period (ANMAC, 2014). COCE are undertaken within all models of maternity care and the requirements surrounding these experiences vary widely by educational institution (Gamble et al., 2020). Midwifery education programs are required to contain equal parts theoretical and clinical hours and those clinical hours not achieved through COCE are undertaken via clinical placements, most often within standard (or fragmented) maternity care models (ANMAC, 2014; Gamble et al., 2020).

Researchers from the Transforming Maternity Care Collaborative recently published an integrative literature review which set out to discover how well pre-registration midwifery education prepares and motivates Australian midwifery students to work in continuity of midwifery care models when they enter practice (Carter et al., 2020). The findings reveal that access and exposure to CoMC is a crucial component of midwifery education. The full text of the paper is available free via this link for a short time.

Midwifery students consistently expressed that their COCE  equipped them with increased knowledge, skills, and confidence in midwifery practice (Browne et al., 2014; Dawson et al., 2015; Fenwick et al., 2016; McKellar et al., 2014; Sidebotham et al., 2015). Their COCE enabled them to build trusting relationships with women, enabling them to recognise and provide woman-centred midwifery care (Browne et al., 2014; Dawson et al., 2015; Fenwick et al., 2016; McKellar et al., 2014; Sidebotham et al., 2015). These factors improved work satisfaction amongst midwifery students and motivated them to provide CoMC upon entry to practice (Brown et al., 2014; Evans et al., 2020; McLachlan et al., 2013; Sidebotham et al., 2015; Sidebotham & Fenwick 2019). Midwifery support played an important role in influencing students learning and future career aspirations (Carter et al., 2015; Sidebotham & Fenwick 2019). Continuity of mentorship from a midwife, who worked in, and whose midwifery philosophy aligns with continuity of care, improved students’ understanding of the role, providing opportunity for them to gain insight into what working in these models really ‘looks like’ (Carter et al., 2015; Sidebotham & Fenwick, 2019).

Some midwifery students reported challenges in the achievement of their COCE. The most common concern was that of the impact on their work/ life balance and, to some extent, their finances (Brown et al., 2014, Carter et al., 2015; Dawson et al., 2015; Fenwick et al., 2016; McLachlan et al., 2013; Sidebotham & Fenwick 2019). It was evident from this research that existing methods of education program delivery and institutional structures often presented students with challenges, detracting from the value of their learning experiences. This was not the case however, when students’ clinical experiences took place within an established CoMC model (Sidebotham & Fenwick, 2019). When academic institutions actively support CoMC by prioritising and embedding it within program delivery, the challenges associated with CoMC are minimised (Sidebotham & Fenwick, 2019). These findings are in alignment with work by Gamble et al. (2020), who suggest that CoMC should become the core principle around which midwifery education programs are designed and delivered.

This integrative review found that while most midwifery students wished to work in continuity of midwifery care, not all felt able or capable to do so upon completion of their education. With motivation high, it is important to identify, expand, and promote factors that increase new midwives’ preparedness to work in CoMC. With little evidence as to how well theoretical and non-CoMC clinical learning prepares students to work in CoMC, further research is required to identify educational factors that enable and inhibit midwives from working this way upon entry to practice. Such research could be used to inform and implement a consistent approach to midwifery education internationally.

References

ANMAC (2009). Midwife accreditation standards 2009. 

ANMAC. (2014). Midwife accreditation standards 2014. 

Browne, J., Haora, P. J., Taylor, J., & Davis, D. L. (2014). “Continuity of care” experiences in midwifery education: Perspectives from diverse stakeholders. Nurse Education in Practice, 14, 573-578.

Carter, J., Dietsch, E., & Sidebotham, M. (2020). The impact of pre-registration education on the motivation and preparation of midwifery students to work in continuity of midwifery care: An integrative review. Nurse Education in Practice, 48, 102859.

Dawson, K., Newton, M., Forster, D., & McLachlan, H. (2015). Exploring midwifery students׳ views and experiences of caseload midwifery: A cross-sectional survey conducted in Victoria, Australia. Midwifery, 31, e7-e15. doi:10.1016/j.midw.2014.09.007

Evans, J., Taylor, J., Browne, J., Ferguson, S., Atchan, M., Maher, P., Homer, C. & Davis, D. (2020). The future in their hands: Graduating student midwives’ plans, job satisfaction and the desire to work in midwifery continuity of care. Women and Birth, 33(1), e59-e66.

Fenwick, J., Gamble, J. & Sidebotham, M. (2016). Being a young midwifery student: A qualitative exploration. Midwifery, 39, 27-34.

Gamble, J., Sidebotham, M., Gilkison, A., Davis, D., & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women and Birth, 33(2), 111-118.

McKellar, L., Charlick, S., Warland, J. & Birbeck, D. (2014). Access, boundaries and confidence: The ABC of facilitating continuity of care experience in midwifery education. Women and Birth, 27(4), e61-e66.

McLachlan, H. L., Newton, M., Nightingale, H., Morrow, J. & Kruger, G. (2013). Exploring the ‘follow-through experience’: A statewide survey of midwifery students and academics conducted in Victoria, Australia. Midwifery, 29(9), 1064-1072.

Sidebotham, M., Fenwick, J., Carter, A. & Gamble, J. (2015). Using the five senses of success framework to understand the experiences of midwifery students enrolled in an undergraduate degree program. Midwifery, 31(1), 201-207.

Sidebotham, M. &Fenwick, J. (2019). Midwifery students’ experiences of working within a midwifery caseload model. Midwifery, 74, 21-28.

Building birthing on country for the Yuin community

First Nations women of Australia have given birth on their country and within their cultural practices for most of their history. The colonisation of Australia by Europeans disrupted this, and it is now challenging for Aboriginal and Torres Strait Islander women to access maternity care that is local to them, and which honours their culture. Midwifery continuity of care delivered in models designed by and for Aboriginal and Torres Strait Islander women, by clinicians who are answerable to their local community can build the strength and vitality of communities.

The IBUS study (Hickey, et al., 2018) has been examining the outcomes of providing birthing on country services within a midwifery continuity of care model. Preliminary findings have shown a significant reduction in preterm birth rates (Kildea, et al., 2019). Preterm birth rates are higher for children born to indigenous women compared to non-indigenous women, and these children are at a life-long disadvantage. Few interventions designed to prevent preterm birth have been as effective as these structural changes to the way care is provided. Despite this, midwifery continuity of care models remain limited around Australia and access to such care is particularly lacking for Aboriginal and Torres Strait Islander women living in regional areas.

Waminda, the South Coast Women’s Health and Welfare Aboriginal Corporation – located on Yuin land in Nowra, NSW – is poised to solve this access issue for their local community. Extensive consultation within the community occurred in 2017 in the form of the Building on Our Strengths (BOOSt) project (Roe, Kildea, & Briggs, 2017). Participants identified that they wanted maternity systems based on Aboriginal ways of knowing and doing, that provide holistic care, and that were committed to giving their children the best start in life.

Waminda have designed a Birthing on Country program that puts the needs of the community first and is underpinned by sound research. A central part of this program is to build a Birthing and Community Hub which will enable the provision of maternity services, including birthing services. The major obstacle in their way at the present time is funding. To overcome this, Waminda are seeking public funding for the project. You can help make this happen by making a donation to support this work.  More information is available on the Waminda Birthing on Country website.

 

References
Hickey S, Roe Y, Gao Y, Nelson C, Carson A, Currie J, et al. The Indigenous Birthing in an Urban Setting study: the IBUS study: A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia. BMC Pregnancy Childbirth. 2018;18(1):431.

Kildea, S., Gao, Y., Hickey, S., Kruske, S., Nelson, C., Blackman, R., Tracy, S., Hurst, C., Williamson, D., & Roe, Y. (2019, Jul). Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia. EClinicalMedicine, 12, 43-51. https://doi.org/10.1016/j.eclinm.2019.06.001

Roe, Y., Kildea S. and Briggs, M. (2017). Birthing on Country, Best Start to Life, Illawarra Shoalhaven, 2017. Birthing on Country Working Group, Midwifery Research Unit, University of Queensland.

Epidural analgesia for labour: An update on labour, birth and perinatal outcomes

The use of epidural analgesia for labour is common, with just over 40% of Queensland women making use of it (Queensland Health, 2020). Epidural analgesia is widely considered to be a safe option. Transforming Maternity Care Collaborative researcher Dr Elizabeth Newnham led a team of researchers who recently examined outcomes for women who did, and did not, make use of epidural analgesia for labour (Newnham et al., 2020).

Data were collected as part of the Maternal health and Maternal Morbidity in Ireland (MAMMI) study which prospectively explored the health of women giving birth for the first time, between 2012 and 2017 in Ireland. Women who gave birth by caesarean section prior to the onset of labour were not included. Care was taken to statistically control for the effects of age, body mass index, and maternity care pathway (public or private care). Data from the birth through to three months postpartum were available for 1,221 women in total.

Women giving birth for the first time who used epidural analgesia were more likely to give birth with vacuum assistance (22.1% without epidural, 25.5% with epidural use) or forceps assistance (4.2% without epidural, 17.4% with epidural). This finding probably relates to the longer duration of the second stage of labour (average of 35 mins without epidural vs 213 mins with epidural). Caesarean section rates were much higher in women who used epidural analgesia (3.4% without epidural, 32.2% with epidural). Seventy percent of women who laboured without an epidural had a spontaneous vaginal birth, while only 24.9% of women with epidural analgesia did so.

Intravenous oxytocin and antibiotics were more commonly used in labour for women using epidural analgesia. The use of antibiotics possibly relates to the higher rate of fever during labour in women using epidural analgesia (0.8% without epidural analgesia, 9.1% with epidural analgesia). Rate of perineal trauma or postpartum haemorrhage were no different between the two groups.

No differences in Apgar scores (either at 1 min or 5 mins), or in the rate of admission to the neonatal intensive care nursery were found. Breastfeeding rates were lower at three months for women who has used epidural analgesia (63.1% without epidural analgesia, 47.5% with epidural analgesia).

The findings of this research reflect that found in previous research about epidural use. Given the nature of this type of research, it is not possible to claim that the outcomes seen were a direct consequence of epidural use. The information set out in the study  provides a useful starting point for obstetricians and midwives as they work with women to support them to make informed decisions about their care.

References

Newnham, E. C., Moran, P. S., Begley, C. M., Carroll, M., & Daly, D. (2020, Sep 11). Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study. Women Birth, in press. https://doi.org/10.1016/j.wombi.2020.09.001

Queensland Health. (2020). Queensland Perinatal Statistics 2019. Interim Report. https://www.health.qld.gov.au/hsu/peri/peri2019/queensland-perinatal-statistics-2019

Access to midwifery continuity of care for childbearing women in the Australian health system

Equitable access to high quality maternity care is a critical priority for all health systems (Koblinsky et al. 2016; United Nations 2019). Strong evidence show that continuity of care delivered by a known midwife is safe, confers significant health benefits for women and babies, and results in higher reported satisfaction with care (Forster et al. 2016; Sandall et al. 2016). Not only is continuity of midwifery care linked to improved outcomes in general populations of childbearing women and those with social risk factors, studies also demonstrate the model meets the triple aims of health system improvement – improved satisfaction, better health care, and cost effectiveness (APPGGH 2016; Berwick 2008).

Despite this evidence, only a small proportion of women have access to continuity of midwifery care.  Scaling up access for women in vulnerable groups presents additional challenges (Renfrew et al. 2019). It’s important to know where families have or do not have access to high quality maternity care across birth settings, so that solutions can be found. A team of researchers from the Transforming Maternity Care Collaborative, led by Dr Rosalyn Donnellan-Fernandez have recently used modelling to provide a snapshot of the progress that is being made in Queensland towards providing universal access to publicly funded models of care (Donnellan-Fernandez et al., 2020).

2017 data for Queensland health services provided information about the number of services offering a midwifery continuity of carer model and the number of full-time equivalent midwives employed in such models. Assuming that each full-time equivalent midwife provided care to 35 women annually formed the basis of the model.

Almost 40,000 births occurred in public hospitals (excluding the Mater) in 2017. Overall, 18% of Queensland women who gave birth that year would have had access to a midwifery continuity of care model. When comparing hospitals by the number of births, geographical location, and whether they operated as a tertiary referral service, significant variations were present. Hospitals with a birth rate of 500 – 2000 births had the lowest estimated access to midwifery continuity of care at 11%. 11,830 women gave birth in these hospitals, almost 30% of the births in 2017.

Three large tertiary hospitals were the site of another 30% of the births. 17% of women giving birth in these facilities were estimated to have access to midwifery continuity of care. Five remote hospitals (providing birth care for 2%) had the highest rate of access at 77%, however this rate was noted to not reflect the full picture for these services. High rates of both planned and emergent antenatal and intrapartum transfer (from 30 to 90%) have been reported for these services. The estimated rates of access to midwifery continuity of carer include women who received antenatal and / or postnatal care in these five hospitals, but who gave birth elsewhere, therefore providing an artificially high estimate.

The authors concluded:

“scaling-up continuity of midwifery care models remains an important public health strategy to address equitable service access and disparate maternal and infant health outcomes.”

References
All Party Parliamentary Group on Global Health (APPGGH). (2016). Triple Impact Report. How developing nursing will improve health, promote gender equality and support economic growth. 

Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The triple aim: Care, health, And cost. Health Affairs, 27(3), 759-769.

Donnellan-Fernandez, R. E., Creedy, D. K., Callander, E. J., Gamble, J., & Toohill, J. (2020, Aug 28). Differential access to continuity of midwifery care in Queensland, Australia. Australian Health Review, in press. https://doi.org/10.1071/AH19264

Forster D.A., McLachlan, H.L., Davey, M.A., et al. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth, 28, 2016.

Koblinsky, M., Moyer, C., Calvert, C., Campbell, J., Campbell, O., Feigl, A., Graham, W., Hatt, L. Hodgins, S., Matthews, Z., McDougall, L., Moran, A., Nandakumar, A., Langer, A. (2016). Quality maternity care for every woman everywhere: a call to action. Lancet, 388, 2307-2320.

Renfrew, M., Ateva, E., Dennis-Antwi, J., Davis, D., Dixon, L., Johnson, P., Powell Kennedy, H., Knutsson, A., Lincetto, O., McConville, F., McFadden, A., Taniguchi, H., Ten Hoope Bender, B., Zeck, W. (2019). Midwifery is a vital solution—What is holding back global progress? Birth, 46, 396-399.

Sandall, J., Soltani, H., Gates, S., Shennan, A., Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, CD004667.

United Nations. (2019). The Sustainable Development Goals Report 2019. Department of Economic and Social Affairs: UN. New York.

Psychological trauma regarding birth and helpful responses – Podcast

This week is Birth Trauma Awareness week. There is increasing recognition that a significant proportion of women describe some aspect of their birth as traumatic. This week provides an opportunity to focus on what can be done to prevent, and respond appropriately to, women’s experiences of their births as a form of psychological trauma.

Professor Jenny Gamble, Director of Transforming Maternity Care, recorded a podcast with Annalee Atia from Pregnancy Birth and Beyond earlier this week. In the podcast Professor Gamble explained that women may experience their birth as traumatic if they feel that there was threat to their life or safety or their baby’s (or babies’) life or safety. About 30% of Australian women report that their birth was traumatic and have some trauma symptoms at 4-6 weeks after birth.

All women should be asked about their birth experience and provided with sufficient time and empathy to be able to talk about it. The process of care is key to whether women experienced birth as traumatic. Technically poor care, failures of communication, care with coercion and without consent, and excluding the woman from decision making contribute to experiencing the birth as traumatic.

Human intent in the harm or threat experienced is significant in the development of traumatic stress and PTSD. If women feel their trust was betrayed or that they received treatment with callous disregard they are more likely to experience birth as traumatic.

The podcast explains helpful early responses for maternity care providers and others. For some women, following the trauma and the struggle to cope and work through the impact of their birth experience, report positive change and growth. These women are beacons of hope and often an empathetic ‘home’ for others experiencing adversity.

You can listen to the Podcast here. Other events held during Birth Trauma Awareness week are hosted on the Facebook page of the Maternal Mental Health Matters Australia 2020 group, along with helpful resources for people who have been affected by birth trauma.

Mental health screening during pregnancy and after birth is even more important right now

Professor Debra Creedy 

Up to 15% of pregnant women in Australia, and 21% of mothers of infants up to four months of age will experience depression. The presence of anxiety, which frequently co-exists with depression, is estimated to also be as high as 20%. Depression during pregnancy and/or the postpartum period can have profound effects on not only a woman’s long-term health and well-being but can also adversely affect her relationship with the baby and her partner.

We currently don’t know the impact of life changes and restrictions related to COVID 19 on the emotional wellbeing of childbearing women. A systematic review of clinical outcomes of 3559 hospitalised patients (in 72 different studies) was published in the Lancet (18th May, 2020). Rogers and colleagues concluded that if the pattern for COVID 19 follows that of similar pandemics (such as SARS in 2002) many admitted patients will experience confusion, acute depression, anxiety, and sleep difficulties. After the illness, 32.2% patients from these combined studies reported post-traumatic stress, and around 15% reported symptoms of depression and anxiety. This data highlights the importance of assessing the emotional wellbeing of not only people with COVID19 but for members of the community who may be at risk, such as pregnant women. However, the approach to screening for depression and/or anxiety during pregnancy and the postpartum varies a great deal.

In an effort to promote common approaches to assessment and measurement of patient outcomes and experiences, core outcome sets are being developed for a range of conditions and used in practice. A core outcome set is an agreed set of outcomes that should be measured and reported. In 2016 the International Consortium for Health Outcomes Measurement (ICHOM) published a core outcome set to evaluate value in maternity care. Acknowledging mental health as an outcome important to women, the ICHOM Working Party included the Patient Health Questionnaire (PHQ-2) and the Edinburgh Postnatal Depression Scale (EPDS) to measure symptoms of perinatal depression.

Currently in Australia, United States, and Canada clinical guidelines recommend that all women should be screened during pregnancy and at least once in the postpartum using the Edinburgh Depression Scale (EPDS). Whereas in the United Kingdom, health professionals undertake selective screening using two brief questions similar to the PHQ-2 – During the past 2 weeks, have you been bothered by (1) ‘feeling down, depressed or hopeless’; and (2) ‘little interest or pleasure in doing things’. If a woman says ‘yes’ (been bothered for several days =1; more than half the days = 2; or nearly every day =3) to one or both questions, then she is asked to complete the EPDS (10 questions). Subsequently, ICHOM recommended using the 2-item PHQ-2 to screen all women, followed by the EPDS if a woman obtains a score of 3 or more (known as a ‘positive’ screen). But the extent to which the PHQ-2 could correctly identify and not miss childbearing women at risk of depressive symptoms had not been tested and further research was needed.

We aimed to compare the screening accuracy of the PHQ-2 to identify women at risk of probable depression during pregnancy and the postpartum. We recruited 309 pregnant women who completed the PHQ-2 and EPDS (at their booking-in appointment around 36-weeks) and postpartum (at 6 and 26-weeks) 4.

The accuracy of the PHQ-2 was tested using two methods (1) scored cut-points >2 and >3, and (2) dichotomous yes/no (positive response to either question) against EPDS cut-points for probable major and probable minor depression. We were interested in the ‘sensitivity’ of the tool – that is, the ability of the PHQ-2 to correctly identify women with depression (known as the true positive rate), and ‘specificity’ – the ability of the PHQ-2 to correctly identify those women who do not have depression (true negative rate).

Our analysis revealed that the dichotomous yes/no (positive response to either question) had the highest sensitivity (81 – 100%). While specificity was low (60 – 74%) we felt that this shortcoming was outweighed by the ability of the PHQ-2 to correctly identify those women at risk for depression.

COVID19 will challenge the mental health of many people in our community, so we shouldn’t stop mental health screening. Our research highlights the importance of supporting women’s mental health through pregnancy and the first year post birth, and why having screening tools that are simple, easy to use tools, and ‘fit for purpose’ in the face of changes to care provision are important. Women receiving continuity of care from a known midwife throughout pregnancy and up to 6 weeks postpartum are more likely to be screened for depression and are more likely to confide in their midwife about concerns and worries.