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COVID-19 related maternity restrictions – more harm than good?

COVID-19 maternity care restrictions

During the global COVID-19 pandemic, maternity care guidelines have been produced rapidly and largely without evidence (Pavlidis et al., 2021). For example, US labour and birth guidelines encouraged providers to use artificial rupture of membranes; use higher doses of oxytocin to shorten length of labour; offer early epidurals; and lower the threshold for caesarean section (Stephens et al., 2020). Across the globe, women have experienced significant restrictions including prohibition of a birth companion in labour, limits around breastfeeding, and reduction in contact between mother and baby (Topalidou et al., 2020). While pregnant women commonly feel fear, stress, or concern about loss of agency during childbirth – COVID-19 has amplified these experiences by adding unknown factors about labour support and medical interventions (Almeida et al., 2020). Fears about restrictions include having to choose between a partner and a doula for labour support, or not having a labour support person at all, and fear of being separated from their baby after birth (Groschow & Floyd, 2021).

In the US, Gutschow & Davis-Floyd (2021) report recent lifting of non-evidence-based restrictions in terms of labour support, immediate skin-to-skin contact, breastfeeding and rooming-in. In Australia, however, there is community concern about increased maternity care restrictions on presence of partners at birth and on the postnatal ward, as reported by the ABC and Guardian. Researchers worldwide have raised concerns about the potential for restrictions to have long-term negative clinical and psychosocial consequences for mothers, families, and babies (Topalidou et al., 2020).

Women’s right to clinically and psychologically safe care

An article was recently published by a team who work across Europe “to ensure women’s rights to give birth in a clinically and psychologically safe environment including during the current COVID-19 pandemic” (Lalor et al., 2021). The commentary includes findings from a two-day virtual meeting of the network that included 88 clinicians and researchers from a variety of disciplines (e.g., midwifery, obstetrics, nursing, psychology) alongside lay advocacy groups from altogether 32 participating countries (Lalor et al., 2021). Information about variations in maternity care and COVID-19 related restrictions were discussed and summarised (Lalor et al., 2021).

Maternity care restrictions inconsistent and without evidence-base

The application of guidelines and restrictions was highly inconsistent between European countries (Lalor et al., 2021). Furthermore, local application of non-evidence-based restrictions significantly deviated from recommendations from the World Health Organization and professional bodies (Lalor et al., 2021). Similar international inconsistencies have been reported in intrapartum care practices outside Europe – including Australia and the United States. For example, use of nitrous oxide and water immersion during labour, birth companions, delayed cord clamping, and isolation of the newborn after birth (Pavlidis et al., 2020).

Lalor et al. (2021) raise concerns that women are being exposed to an environment where traumatic birth experiences are more likely – and where the continued implementation of harmful practices constitute a human rights violation (Lalor et al., 2021). The authors highlight that maternity care providers may be following guidelines that contradict with evidence, professional recommendations and/or deeply held values around woman-centred care – which in turn affects staff morale and productivity (Lalor et al., 2021). Indeed, a survey of key stakeholders in Australian maternity care reported that midwives and midwifery students are largely dissatisfied with restrictions that limit the quality of care they can provide (Bradfield et al., 2021).

Recommendations for maternity services and policymakers

Renfrew et al. (2020) provide key principles for services to sustain quality care during the pandemic. These include continuing to provide “evidence-informed, equitable, safe, respectful, and compassionate care for the physical and mental health of all women and newborn infants, wherever and whenever care takes place” (Renfrew et al., 2020). More specifically they recommend maintaining community-based continuity of care models, ensuring access to chosen birth support, facilitating mother-baby contact at birth, and promoting breastfeeding (Renfrew et al., 2020).

Any proposed change to maternity care practice must be considered within a quality framework, based on evidence, and evaluated for unintended effects (Lalor et al., 2021). Furthermore, women, families and staff should co-design proposed changes (Renfrew et al., 2020). Policies in response to COVID-19 have not been sensitive to maternal health – this could be addressed through the inclusion of maternal health experts in emergency planning – as well as rapid monitoring of barriers to maternity care (Takemoto et al., 2021).

Highlighted research

Lalor, J., Ayers, S., Celleja, J., Downe, S., Gouni, O., Hartmann, K., Nieuwenhuijze, M., Oosterman, M. Turner, J. D. (accepted in press, 2021). Balancing restrictions and access to maternity care for women and birthing partners during the COVID-19 pandemic: the psychosocial impact of suboptimal care. BJOG https://doi.org/10.1111/1471-0528.16844

References

Almeida M, Shrestha A. D., Stojanac B., Miller L J. (2020). The impact of the pandemic of women’s mental health. Archives Women’s Mental Health 23 (7), 741-748.  https://doi.org/10.1007/s00737-020-01092-2

Bradfield, Z., Wynter, K., Hauck, Y., Vasilevski, V., Kuliukas, L., Wilson, A. N., Szabo, R. A., Homer, C., & Sweet, L. (2021). Experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia: A five-cohort cross-sectional comparison. PloS one16(3), e0248488. https://doi.org/10.1371/journal.pone.0248488

Gutschow, K., & Davis-Floyd, R. (2021). The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study. Frontiers in Sociology6, 655401. https://doi.org/10.3389/fsoc.2021.655401

Pavlidis, P., Eddy, K., Phung, K., Farrington, E., Connolly, M., Lopes, R., Wilson, A.N., Homer, C.S.E., Vogel, P. (2020). Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth, and the immediate postpartum period. Women and Birth. https://doi.org/10.1016/j.wombi.2020.10.015

Renfrew, M. J., Cheyne, H., Craig, J., Duff, E., Dykes, F., Hunter, B., Lavender, T., Page, L., Ross-Davie, M., Spiby, H., & Downe, S. (2020). Sustaining quality midwifery care in a pandemic and beyond. Midwifery88, 102759. https://doi.org/10.1016/j.midw.2020.102759

Stephens A. J., Barton J. R., Bentum N.-A. A., Blackwell S. C., Sibai B. M. (2020). General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic. American Journal of Perinatolology, 37, 08, 829–836.

Topalidou, A., Thomson, G., Downe, S. (2020). COVID-19 and maternal and infant health: Are we getting the balance right? A rapid scoping review. The Practising Midwife, 23, 36- 45.

 

Midwifery centres – the what, the how, the why

Women across the globe (in low-, middle- and high-income countries) are concerned about misuse of medical intervention, and disrespectful or abusive treatment during labour and birth (World Health Organization, 2014). For example, in Mexico where the caesarean section rate is 50%, 30% of women report they have experienced ‘obstetric violence’ (Alonso et al., 2018). Whereas the poorest women in Sub Saharan Africa usually give birth at home either unattended (56%) or with a traditional birth attendant (41%), because they lack access to a skilled birth attendant, or do not think one is needed (Montagu et al., 2011). Midwifery centres – also known as birth centres – are sought by women who want to experience safe, respectful, and satisfying birth in a facility, while avoiding unnecessary intervention (Stevens & Alonso, 2020).

What is a midwifery centre?

A Midwifery Centre is a home-like healthcare facility that is guided by a midwifery philosophy of care, centred on the woman’s experience, specialising in physiological birth, with access to basic emergency care, and fully integrated within the healthcare system (Stevens & Alonso, 2020). Midwifery centres operate all over the world in over 56 countries – see map here. While midwifery centres could be key to achieving quality maternal and newborn care, there are negative perceptions about their capacity, limited understanding of what midwives do, and lack of access globally.

Midwifery centres in high-income countries

In high-income countries (e.g., Australia, Canada, United Kingdom, United States) highest-level evidence demonstrates women who plan to birth in a midwifery centre have a higher chance of normal birth, with a lower chance of obstetric intervention, and no difference in infant mortality (Scarf et al., 2018). Approximately 3% of women in Australia give birth in a midwifery centre. A study in one Australian state determined that 34% of women having their first baby, and 12% of women having a subsequent baby, were transferred from a midwifery centre and gave birth in hospital (Scarf et al., 2019). While there has been a near doubling of demand for midwifery centres in Australia over the past two decades, access has remained limited and birth numbers in midwifery centres have been static (Adelson et al., 2021).

Midwifery centres in low-income countries

In low- and middle- income countries, less is known about the outcomes associated with midwifery centre care. In these settings, there are challenges including lack of equipment, supplies, medication, blood, electricity and water; combined with difficulty transferring women to higher level care when needed either through lack of transport or women’s unwillingness to access hospital care (Munabi-Babigumira et al., 2017). Furthermore, midwifery centres in low- and middle- income countries tend to operate outside the healthcare system. Safe and respectful care, with seamless access to higher level services when required, is key to increasing access to skilled birth attendants in low- and middle-income countries; and therefore, addressing maternal and infant mortality in these settings.

How standards contribute to quality care

Without international standards, including a consensus definition of what a midwifery centre is (and is not), it is difficult to implement, monitor, evaluate and scale up.  Rigorously developed international standards guide funders, policy makers, managers and maternity advocates. It is important to be able to measure and compare outcomes between midwifery centres within and between countries, while accounting for variation in the population.

Development of international standards

Researchers Stevens & Alonso (2021) wanted to develop clear guidance through international standards to ensure the quality of care provided in midwifery centres. To do this, they initially gathered midwifery centre operation standards from the United States and Europe and compared these with international guidance on quality of maternal and newborn care, rights of childbearing women, and respectful maternity care (Stevens & Alonso, 2021). The research team analysed the documents to determine commonalities and to develop draft international standards. Next, international experts in low-, middle- and high-income settings provided feedback on the draft standards. The researchers then piloted 52 standards at 8 midwifery centres in 8 countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda, and Trinidad) (Stevens & Alonso, 2021). Discussions with the pilot sites helped determine the final list.

Assessing how midwifery centres meet international standards

The Operational Standards for Midwifery Centers are freely available here. There are 43 process standards in three domains: Dignity, Quality, and Community-Facility (Stevens & Alonso, 2021). Each standard includes indicators which can be used to measure and assess whether, and how, the standard is met. Dignity includes 13 standards that are focussed on the woman. For example, Standard 10 Every mother is informed about the benefits of supporting physiological processes, includes indicators like policy, and woman’s health record. Quality includes 13 standards that are focussed on the maternity care providers. For example, Standard 24 At every birth, there are at least two staff currently trained for emergency management of common birth complications, can be assessed through staff education logs and birth documentation. Community-Facility includes 17 standards that are about administration. For example, Standard 31 The facility has functioning, reliable, safe, and sufficient systems for each of the following: clean water, dependable energy, facility sanitation, hand hygiene, general waste disposal, and medical waste disposal, can be assessed through availability of policies and procedures.

Primary midwifery care is the solution

Some argue that universal access to high-quality obstetric care and facility-based birth is the path to address maternal and infant mortality in low- and middle-income countries (Bohren et al., 2014). From this perspective, midwives are seen as an ‘add on’ to provide emotional support during obstetric-led birth (Austad et al., 2021). An alternative solution, that would address women’s expressed desires to birth close to home, with minimal intervention, and avoid disrespectful care, would be to rapidly scale up midwifery centres that meet international standards. Primary midwifery care should be the foundation of any maternity system. Midwives need to be supported in systems and health services to deliver care and outcomes for women and babies.

Scale-up of midwifery centres

Using the term ‘midwifery centre’ instead of ‘birth centre’ may help reorient thinking about how best to organise and provide quality maternal and newborn care. In high-income settings, a midwifery centre is not a room with an armchair and a birth pool within an obstetric-led unit. Midwifery centres are midwifery-led, woman-centred – designed to promote physiological birth and enable midwives to work to their full scope of practice. In low- and middle-income settings, a facility outside the hospital that offers birth care, but is not fully integrated to enable consultation, referral and transfer to higher level services, is also not a midwifery centre. The consensus definition and operational standards can be used in any global setting to establish, monitor and scale-up midwifery centres.

Highlighted research

Stevens, J. R., & Alonso, C. (2021). Developing operational standards for Midwifery Centers. Midwifery, 93, 102882. https://doi.org/10.1016/j.midw.2020.102882

References

Adelson, P., Fleet, J. A., McKellar, L., & Eckert, M. (2021). Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016. Women and Birth34(1), e84–e91. https://doi.org/10.1016/j.wombi.2020.05.005

Alonso, C., Storey, A. S., Fajardo, I., & Borboleta, H. S. (2021). Emergent change in a Mexican midwifery center organization amidst the COVID-19 crisis. Frontiers in Sociology6, 611321. https://doi.org/10.3389/fsoc.2021.611321

Austad, K., Juarez, M., Shryer, H. et al. (2021). Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy and Childbirth, 21, 425. https://doi.org/10.1186/s12884-021-03842-1

Bohren, M.A., Hunter, E.C., Munthe-Kaas, H.M. et al. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health, 11, 71.

Montagu D, Yamey G, Visconti A, Harding A, Yoong J (2011) Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLOS ONE, 6(2): e17155. https://doi.org/10.1371/journal.pone.0017155

Munabi-Babigumira, S., Glenton, C., Lewin, S., Fretheim, A., & Nabudere, H. (2017). Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. The Cochrane Database of Systematic Reviews11(11), CD011558. https://doi.org/10.1002/14651858.CD011558.pub2

Scarf, V. L., Viney, R., Yu, S., Foureur, M., Rossiter, C., Dahlen, H., Thornton, C., Cheah, S. L., & Homer, C. (2019). Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012. BMC Pregnancy and Childbirth19(1), 513. https://doi.org/10.1186/s12884-019-2584-0

Scarf, V. L., Rossiter, C., Vedam, S., Dahlen, H. G., Ellwood, D., Forster, D., . . . Homer, C. S. E. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis. Midwifery, 62, 240-255. https://doi.org/10.1016/j.midw.2018.03.024

Stevens, J. R., & Alonso, C. (2020). Commentary: Creating a definition for global midwifery centers. Midwifery, 85, 102684. https://doi.org/10.1016/j.midw.2020.102684

World Health Organization. (2014). Prevention and elimination of disrespect and abuse during childbirth. Retrieved from: https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/

Strategies that work to increase vaginal birth rate after caesarean

Vaginal birth after caesarean around the world

VBAC is a vaginal birth after caesarean section. While planned VBAC is a safe choice for most women, rates of VBAC vary considerably. VBAC rates are high in countries like Finland, Sweden and Netherlands (approximately 50%), lower in Ireland, Scotland, Italy, Spain and Germany (approximately 30%), and lowest in countries like the US and Australia (approximately 12%) (Lundgren et al., 2020). Indeed, the rate of successful VBAC in Australia has remained stagnant over the past decade – 13.1% in 2007 to 12.1% in 2018 (Australian Institute of Health and Welfare, 2020).

Research finds that in settings where rates are low , VBAC is not considered the obvious first choice for most women (Lundgren et al., 2020). Furthermore, obstetricians tend to determine whether VBAC should be attempted in countries with low-rates rather than women themselves (Lundgren et al., 2020). In a recent US study, women described having to “fight hard” for a VBAC including navigating obstacles, finding a supportive care provider, and sometimes travelling long distances to access care (Basile Ibrahim et al. 2021). Wingert et al. (2018) conducted a systematic review of all studies that had looked at the impact of interventions (e.g., education) on planned and/or successful VBAC rates.

Strategies for maternity care providers

Education for healthcare providers about the benefits of VBAC was effective, particularly when it was provided by a respected obstetric opinion leader (Wingert et al., 2018). When doctors were required to seek a second opinion from an obstetrician – regarding first or subsequent caesarean section (CS) – the rates of planned and successful VBACs increased (Wingert et al., 2018). Furthermore, having a night float on-call system which uses doctors who were more rested, compared to doctors on a 24-hour on-call shift, increased VBAC success rates (Wingert et al., 2021). 

Strategies for pregnant and birthing women

The systematic review included several studies that assessed the usefulness of a decision aid, compared to no decision aid, for women choosing between VBAC and CS for their next birth. Every decision aid was associated with an increase in women’s knowledge and decrease in their anxiety about decision –  but none of the decision aids made a difference to planned VBAC rates (Wingert et al., 2018).

Health system strategies

Providing hospitals funding contingent on increasing VBAC rates was an effective strategy in one study (Wingert et al., 2018). Models of care – midwifery continuity of carer, midwifery antenatal continuity, and dedicated VBAC antenatal clinics – were associated with higher rates of planned and successful VBAC compared to standard care (Wingert et al., 2018).

Midwifery continuity of carer models

Women’s experiences of planned VBAC in midwifery continuity of carer models were more positive than standard care (Keedle et al., 2020). For example, women were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC.  Furthermore, women with a known midwife were more likely to have been active in labour, labour in water, and use an upright birth position (Keedle et al., 2020).

A small randomised trial aimed to compare a midwifery continuity of carer model (antenatal, birth, postnatal), with a midwifery antenatal continuity model, on VBAC rates (Homer et al., 2021). In this study, there was no significant difference between midwifery continuity of carer or antenatal continuity for planned VBAC (67% vs 57%) or VBAC success (28% vs 33%)  (Homer et al., 2021). However, the likely reason was that both models were similar to each other (i.e. women saw a similar number of midwives antenatally and during labour and birth) (Homer et al., 2021). Therefore, a trial of midwifery continuity of carer – using a model where a genuine and trusting relationship can develop between midwife and woman – is still required (Homer et al., 2021).

Recommendations to support VBAC

Health services should increase access to models of care that include a significant role for midwives, and use evidence-based strategies that proactively encourage vaginal birth for women after previous CS (Davis et al., 2020).

Maternity care providers can facilitate women to plan a VBAC by providing information in a supportive way, viewing VBAC as the first alternative in the absence of complications, and helping women to ‘let go’ of their previous childbirth experience to prepare for their next birth (Nilsson et al., 2017). The discussion of risks and benefits for next birth after CS, should include information about recovery from surgical birth (Davis et al., 2020). During labour, midwives and obstetricians can help women achieve a VBAC by offering calm and confident support  (Nilsson et al., 2017).

A national mass media public health campaign about the benefits of VBAC has been an effective strategy in one country with low rates of planned VBAC. Women who viewed the campaign had increased self-reported knowledge, positive attitude towards VBAC and higher intention toward VBAC (Majilesi et al., 2020). A similar campaign could be considered in other countries with low rates of VBAC intention.

Highlighted research

Homer, C., Davis, D. L., Mollart, L., Turkmani, S., Smith, R. M., Bullard, M., Leiser, B., & Foureur, M. (2021). Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial. Women and Birth, S1871-5192(21)00089-5. Advance online publication. https://doi.org/10.1016/j.wombi.2021.05.010

References

Australian Institute of Health and Welfare. (2020). National Core Maternity Indicators 2018: summary report. Retrieved from Canberra: https://www.aihw.gov.au/reports/mothers-babies/national-core-maternity-indicators-summary-report

Basile Ibrahim, B., Knobf, M. T., Shorten, A., Vedam, S., Cheyney, M., Illuzzi, J., & Kennedy, H. P. (2021). “I had to fight for my VBAC”: A mixed methods exploration of women’s experiences of pregnancy and vaginal birth after cesarean in the United States. Birth (Berkeley, Calif.)48(2), 164–177. https://doi.org/10.1111/birt.12513

Davis, D., S Homer, C., Clack, D., Turkmani, S., & Foureur, M. (2020). Choosing vaginal birth after caesarean section: Motivating factors. Midwifery88, 102766. https://doi.org/10.1016/j.midw.2020.102766

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy and Childbirth20(1), 381. https://doi.org/10.1186/s12884-020-03075-8

Lundgren, I., Morano, S., Nilsson, C., Sinclair, M., & Begley, C. (2020). Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates – A hermeneutic study. Women Birth, 33(4), e339-e347. https://doi.org/10.1016/j.wombi.2019.07.300

Majlesi, M., Montazeri, A., Rakhshani, F., Nouri-Khashe-Heiran, E., & Akbari, N. (2020). ‘No to unnecessary caesarean sections’: Evaluation of a mass-media campaign on women’s knowledge, attitude and intention for mode of delivery. PloS One15(8), e0235688. https://doi.org/10.1371/journal.pone.0235688

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after cesarean: Views of women from countries with high VBAC rates. Qualitative Health Research27(3), 325–340. https://doi.org/10.1177/1049732315612041

Wingert, A., Johnson, C., Featherstone, R., Sebastianski, M., Hartling, L., & Douglas Wilson, R. (2018). Adjunct clinical interventions that influence vaginal birth after cesarean rates: Systematic review. BMC Pregnancy and Childbirth18(1), 452. https://doi.org/10.1186/s12884-018-2065-x

Central fetal monitoring – time to de-implement?

Investment in fetal monitoring technology

Maternity services in high-income countries have invested heavily in medical technologies. However, some technologies have been implemented without clear evidence of clinical benefit or safety. Cardiotocograph (CTG) is commonly used to monitor the fetal heart rate in labour. Professional position statements and clinical guidelines recommend the use of CTG, despite highest-level evidence that it does not improve perinatal outcomes, even for women with risk factors (Small et al., 2020). See more here does-intrapartum-ctg-monitoring-save-lives. Furthermore, one of the unintended consequences of CTG has been escalating rates of caesarean section (Small et al., 2020).

Impact of fetal monitoring technology

Central  monitoring systems (CMS) transmit data from the CTG to a central site where it can be interpreted outside the room. CMS are being rolled out as a valuable add-on to CTGs, yet there have been no randomised trials of CMS. Indeed, the only evidence available is from three small studies that demonstrated CMS do not impact perinatal outcomes (Small et al., 2021). Furthermore, two of the studies measured an increase rates of instrumental birth and caesarean section after CMS was introduced (Brown et al., 2016; Weiss et al., 1997). Additional concerns include that midwives spend less time in the room with labouring women when these are CMS (Brown et al., 2016).

New research with clinicians in a setting with CMS

Obstetrician Dr Kirsten Small (PhD), project lead with Transforming Maternity Care Collaborative, conducted doctoral research about how CMS organise the work of maternity clinicians. Her PhD was supervised by Emeritus Professors Mary Sidebotham and Jenny Gamble, and Professor Jennifer Fenwick. Their latest publication describes how CMS affect maternity care providers clinical behaviours (Small et al., 2021). The setting for this qualitative study was a maternity hospital where 90% of women had a CTG in labour (all connected to a CMS). Thirty-six midwives (including midwifery students), and 16 doctors (including obstetric residents, registrars, and consultants) participated in the study. Dr Small interviewed (individually and in groups) and/or observed (e.g., when interacting with the CMS) participants and then led analysis of the data.

Undermining midwifery autonomy and compromising maternity care

The study found that clinicians outside the room made clinical decisions without all the relevant information, which potentially compromises safety (Small et al., 2021). Informants described how decisions were made, before engaging with the birthing woman and her midwife. Team leaders were perceived to check-in less with individual midwives (i.e., to get updated about the woman’s labour), if they could see that the CTG was normal.

Some midwives felt professionally disrespected by obstetricians, who would see the CMS and enter a room without invitation or permission (Small et al., 2021). This behaviour required midwives to de-escalate concerns, sometimes in a context of forceful obstetric communication. Importantly, this is the opposite of the usual process where midwives escalate concerns based on the midwife’s professional judgement. Taken together, making decisions outside the room, and coming into the room to then bypass or contradict the midwife’s interpretation of the CTG, was perceived to undermine women’s confidence in their midwife (Small et al., 2021).

Midwives lamented they were spending more time documenting on the CMS rather than being with woman. To limit disruptions to the birth space, midwives described changing their practice. For example, midwives limited women’s positions to ensure good contact for a CTG and directed women’s pushing efforts to speed up second stage labour. Informants described obstetricians acting on normal second stage decelerations (seen on the CMS), by performing surgical/instrumental birth.

Time to pause and consider next steps

Maternity services who are considering installation of CMS should pause – further research that demonstrates clinical benefit is required. Maternity services that have installed CMS, should rigorously evaluate the risks and benefits of these systems. Next steps may include the decision to de-implement CMS. De-implementation is the “process of identifying and removing harmful, non-cost-effective, or ineffective practices” (Upvall & Bourgault, 2018, p.495). Unlike implementation research, however, little is known about the process of de-implementation (van Bodegom-Vos et al., 2017). Three criteria have been suggested to help services identify which interventions are appropriate for de-implementation (McKay et al., 2018):

1) not effective or harmful; or

2) not the most effective or efficient to provide; or

3) no longer necessary.

Managers and service leaders have a responsibility to disinvest from technologies that meet any of these criteria.

Highlighted research

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2021). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women and Birth. https://doi.org/10.1016/j.wombi.2021.05.006

References

Brown, J., McIntyre, A., Gasparotto, R., & McGee, T. M. (2016). Birth outcomes, intervention frequency, and the disappearing Midwife—Potential hazards of central fetal monitoring: A single center review. Birth43(2), 100-107.

Burton, C., Williams, L., Bucknall, T. et al. (2019). Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Systematic Reviews, 8(194). https://doi.org/10.1186/s13643-019-1111-8

McKay, V. R., Morshed, A. B., Brownson, R. C., Proctor, E. K., & Prusaczyk, B. (2018). Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. American Journal of Community Psychology62(1-2), 189–202. https://doi.org/10.1002/ajcp.12258

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and birth : journal of the Australian College of Midwives33(5), 411–418. https://doi.org/10.1016/j.wombi.2019.10.002

Upvall, M. J., & Bourgault, A. M. (2018). De-implementation: A concept analysis. Nursing forum, 10.1111/nuf.12256. Advance online publication. https://doi.org/10.1111/nuf.12256

van Bodegom-Vos L, Davidoff F, Marang-van de Mheen PJ. (2017). Implementation and de-implementation: two sides of the same coin? BMJ Quality & Safety, 26, 495-501.

Weiss, P. M., Balducci, J., Reed, J., Klasko, S. K., & Rust, O. A. (1997). Does centralized monitoring affect perinatal outcome?. The Journal of Maternal‐Fetal Medicine6(6), 317-319.

Withiam-Leitch, M., Shelton, J., & Fleming, E. (2007). Central fetal monitoring: Effect on perinatal outcomes and cesarean section rate. Obstetrical & gynecological survey62(4), 232-233.

The midwife’s public health role

Midwifery is a public health strategy

Public health is “the art and science of preventing disease, prolonging life and promoting health” (WHO, 1988). The Quality Maternal and Newborn Care Framework highlights the preventative and supportive care midwives provide – tailored to individual needs and focussed on strengthening capabilities (QMNC, 2021).  Midwives use strategies that prevent or minimise complications during pregnancy, birth, or early parenting – and promote health and well-being (QNMC, 2021). For example, brief-interventions about smoking, screening and support for perinatal mental health, and promotion of normal birth and breastfeeding. The World Health Organization (2020) underscores the importance of working to strengthen families to provide a nurturing environment for children to thrive.

Midwifery continuity provides ideal context for change

Midwives in continuity of carer models are best placed to form genuine caring relationships with women (Jepsen et al., 2016). The midwife-woman relationship provides the context for women to buy-in to maternity care. Women buy-in when they feel safe enough to disclose risks and concerns, and trust and accept the midwife’s recommendations for making positive health changes (Allen et al., 2016).  There is high level evidence for midwifery continuity of care in terms of clinical outcomes (Sandall et al., 2016) and cost-efficiency (Callander et al., 2021). However, the evidence of effective midwifery public health interventions is still growing.

Evidence on midwifery public health interventions

Definitive evidence of effective midwifery public health interventions comes from a systematic review of systematic reviews (McNeill et al., 2012). This study considered the level of evidence included in reviews, and assessed how well each review was conducted. McNeill et al. (2012) identified 36 good quality systematic reviews which reported on effective interventions during the antenatal period (20 reviews), labour and birth (5 reviews) and postpartum (11 reviews). The review included 8 interventions categorised as:

  1. screening
  2. supplementation
  3. support
  4. education
  5. mental health
  6. birthing environment
  7. clinical care in labour
  8. breast feeding

Effective antenatal public health interventions included screening for lower genital tract infection, use of decision-aids, and specific nutrient supplementation – i.e., iron and folic acid (McNeill et al., 2012). However, the review noted a need for further research on calcium supplementation to reduce risk of pre-eclampsia (McNeill et al., 2012). Interventions designed to help women stop smoking during pregnancy were particularly effective (McNeill et al., 2012). While emotional support interventions, including telephone support, showed a trend towards positive psycho-social outcomes – further research is needed (McNeill et al., 2012).

Effective intrapartum public health interventions included having a known midwife, which reduced the risk of intrapartum analgesia and caesarean section, and increased the chance of spontaneous vaginal birth and breastfeeding (McNeill et al., 2012). Other effective interventions included access to birth centres, continuous emotional support in labour, warm water immersion, and delayed cord clamping (McNeill et al., 2012).

Effective postpartum public health interventions, included intensive midwifery home visiting which reduced the incidence of postnatal depression by 33% (Dennis & Creedy, 2004). Indeed, any intervention design to provide psycho-social support (e.g., non-directive counselling, group support) reduced postnatal depression when compared to standard care (McNeill et al., 2012). Interestingly, all types of interventions tested to increase breastfeeding had a positive impact. Antenatal education increased breastfeeding initiation for low-income women, whereas only postnatal interventions had an impact on duration and exclusivity (McNeill et al., 2012). Teaching and enhancing parenting skills improved children’s neurodevelopment up to 3 years of age compared to standard care (McNeill et al., 2012).

COVID-19 and the public health role of midwives

The COVID-19 pandemic has shown the importance of investing in public health care to meet population health needs (Szabo et al., 2021). Dr Zoe Bradfield, Transforming Maternity Care Collaborative’s Health Promotion Program Co-Director, led a survey of midwives about providing maternity care during the pandemic (Bradfield et al., 2021). The results showed that having a known midwife was important particularly when woman had limited face-to-face midwifery contact during pregnancy and postpartum, and restrictions around social support in labour (Bradfield et al., 2021). Women’s experience of becoming mothers during the pandemic created additional needs for psycho-social support to manage isolation, anxiety, and stress; advocacy and access to reliable information; and reassurance (Sweet et al., 2021). Midwives are ideally placed to meet these needs through advocacy, education and support.

Midwifery investment improves public health

There is a lack of understanding about the impact and value of midwifery practice on public health outcomes. The 2021 State of the World’s Midwifery Report calls for significant investment in the education of midwives and expansion of midwifery-led models of care, to promote the health and well-being of mothers and babies (UNPF, WHO & ICM, 2021).  Midwives are essential providers of public health care contributing to improved outcomes, especially for women who may not experience equitable access to maternity care.

Highlighted research

McNeill J, Lynn F. & Alderdice F. (2012) Public health interventions in midwifery: A systematic review of systematic reviews. BMC Public Health, 12, 955. Retrieved from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-955

References

Allen, J., Kildea, S., & Stapleton, H. (2016). How optimal caseload midwifery can modify predictors for preterm birth in young women: integrated findings from a mixed methods study. Midwifery. https://doi.org/10.1016/j.midw.2016.07.012

Bradfield, Z., Hauck, Y., Kuliukas, L., Sweet, L., Homer, C. Wilson, A., Vasilevski, V., Wynter, K. & Szabo, R.(2021). Midwifery care during the CoVID-19 pandemic in Australia: A cross-sectional study. Women and Birth (In Press). https://doi.org/10.1016/j.wombi.2021.02.007

Callander, E. J., Slavin, V., Gamble, J., Creedy, D. K., & Brittain, H. (2021). Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab084

Jepsen, I., Mark, E., Nohr, E. A., Foureur, M., & Sorensen, E. E. (2016). A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives. Midwifery, 36, 61-69. https://doi.org/10.1016/j.midw.2016.03.002

Quality Maternal and Newborn Care. (2021). Framework for Quality Maternal and Newborn Care. Retrieved from: https://www.qmnc.org/qmnc-research-alliance/framework-for-quality-maternal-and-newborn-care/

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, 4, Cd004667. https://doi.org/10.1002/14651858.CD004667.pub5

Sweet, L., Bradfield, Z., Vasilevski, V. Wynter, K.  Hauck, Y., Kuliukas, L., Homer, C., Szabo, R. & Wilson, A. (2021). Becoming a mother in the ‘new’ social world in Australia during the first wave of the COVID-19 pandemic. Midwifery. (In Press)https://doi.org/10.1016/j.midw.2021.102996

Szabo, R. Sweet, L., Homer, C., Wilson, A., Kuliukas, L., Hauck, Y., Vasilevski, V., Wynter, K. & Bradfield, Z. (2021). COVID-19 changes to maternity care: Experiences of Australian doctors. ANZJOGhttp://dx.doi.org/10.1111/ajo.13307

United Nations Population Fund (UNPF), World Health Organization (WHO), & International Confederation of Midwives (ICM).(2021). State of the world’s midwifery: delivering health, saving lives. United Nations Population Fund.

World Health Organization. (2020). Improving Early Childhood Development: WHO Guideline. WHO.

World Health Organization. (1988). Public Health Services. Retrieved from: https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/public-health-services

Facilitating “instant and overwhelming love” should be standard midwifery care

Skin-to-skin contact between a mother and baby at birth

While facilitating immediate and uninterrupted skin-to-skin (S2S) for an hour after birth should be routine care, in most health services it is not. Having a baby in naked body contact with their mother immediately after birth has significant benefits for both. Immediate and sustained S2S (60 minutes or more) offers women physiological benefits including lower risk of postpartum haemorrhage (Saxton et al., 2015). Significantly, S2S increases the chance of having an effective first breastfeed, exclusively breastfeeding at hospital discharge, and sustained breastfeeding up to four months postpartum (Moore et al., 2016). Importantly, S2S offers psychological benefits too including lower symptoms of postpartum anxiety and depression (Kirca et al., 2021). Early S2S strengthens the mother-infant relationship, increases parental confidence, and initiates caregiving behaviours (Bystrova et al., 2009). Women’s experiences of S2S at birth have been summed up as feeling “instant and overwhelming love” (Anderzén-Carlsson et al., 2014). Despite endorsement by the World Health Organization, there has been a significant lag between evidence about S2S and translation into routine midwifery practice (Widström et al., 2019).

Australian women’s experiences of the first few hours after birth

Transforming Maternity Care Collaborative’s Dr Jyai Allen will present findings from an Australia women’s survey at the International Confederation of Midwives Virtual Congress in June 2021. Survey items drew on concepts from two midwifery theories: Birth Territory (Fahy & Parratt, 2006) and Pronurturance (Fahy et al., 2015). The survey link was shared widely on birth and parenting social media groups. The survey was open to women who had given birth in the previous 3-years in any Australian birth setting (hospital, birth centre, home). The main outcome for the study was ‘pronurturance’ defined as immediate S2S (within 1-minute of birth), uninterrupted holding for 60 minutes, and breastfeeding in the birth setting. Statistical testing identified that mode of birth and model of care were the factors that had a significant impact on pronurturance.

Most surveyed women did not experience ‘pronurturance’

Of the 1200 respondents, only 22% experienced all the elements of pronurturance (Allen et al., 2019a). Lack of pronurturance was because:

25% did not have an immediate cuddle

30% did not have any S2S

66% did not hold their baby for at least 60-minutes

19% did not breastfeed in the birth setting.

Women who were aware of the benefits of S2S, were more likely to receive it. Women who did not receive S2S were either wearing clothing that impeded it (60%) or received the baby  wrapped or dressed (40%) (Allen et al., 2019a). Most women (70%) said they would have removed their top / bra if the midwife had suggested it. When the first cuddle was ended before 60-minutes, 80% of women reported that was the choice of staff. The most common reasons were non-urgent: perform a procedure on the mother, weigh the baby, get the woman to shower (Allen et al., 2019a).

What hinders and what helps?

When surveyed women had a known midwife at birth, they were 89% more likely to get pronurturance. High workloads in fragmented models result in “time poverty” which limits the time midwives spend on the psycho-social-emotional elements of birth (Boyle et al. 2016). Whereas in the M@NGO trial, women allocated to midwifery continuity of carer were more likely to perceive their antenatal visits were unhurried and that they had time to ask questions (Allen et al., 2019b). During birth, midwifery continuity models provide explicit support for physiological birth (Kemp & Sandall, 2010), which includes undisturbed third and fourth stages of labour (Fahy et al., 2015). Whereas midwives working shifts are more likely to prioritise institutional needs and less likely to advocate for women they do not know (Finlay & Sandall, 2009).

Surveyed women who had a caesarean section were 93% less likely to receive pronurturance (Allen et al. 2019). We know that women who have a caesarean section commonly have a delay before their first cuddle, are less likely to have S2S, and less likely to breastfeed in the first hour after birth (Stevens et al., 2018). Importantly, however, women who have a caesarean section are more likely to benefit from S2S in terms of birth satisfaction (Kahalon et al., 2021). Changing practice around the time of caesarean section is hard. An implementation study showed that even after a 4-month period of staff education and agreed changes to practice, the increase in S2S contact for 15-minutes in the operating room only moved from 20 to 25 percent (Thompson et al., 2021).

Midwives can make a big difference – but they need support

Midwives and midwifery students are best placed to facilitate immediate and uninterrupted S2S after birth to initiate bonding and breastfeeding. That said, in operating theatre, having a multi-disciplinary team who understand the benefits of S2S and breastfeeding – and actively support it – is crucial to practice change (Thompson, 2021).

Midwives can make a difference by:

  1. Talking to women during pregnancy about the benefits of S2S and how to achieve it
  2. Helping women to remove bras or tops just prior to birth
  3. Assisting women to place the naked baby S2S against her bare chest and keeping baby warm with towels/blankets
  4.  Supporting delayed cord clamping and not separating babies from their mothers (Mejía Jiménez et al., 2021)

Furthermore, health services should prioritise embedding evidence-based practice into routine maternity care. This means identifying and strategically addressing the institutional processes that interrupt mothers and babies in the first hour after birth.

References

Highlighted research:  Allen, J., Parratt, J. A., Rolfe, M. I., Hastie, C. R., Saxton, A., & Fahy, K. M. (2019a). Immediate, uninterrupted skin-to-skin contact and breastfeeding after birth: A cross-sectional electronic survey. Midwifery, 79, 102535-102535. https://doi.org/10.1016/j.midw.2019.102535

Anderzén-Carlsson, A., Carvalho Lamy, Z. & Eriksson, M. (2014) Parental experiences of providing skin-to-skin care to their newborn infant—Part 1: A qualitative systematic review. International Journal of Qualitative Studies on Health and Well-being, 9(1). https://doi.org/10.3402/qhw.v9.24906

Allen, J, Kildea, S, Tracy, MB, Hartz, DL, Welsh, AW, Tracy, SK. (2019b). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth, 46, 439– 449.

Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A-S, Ransjo-Arvidson, A-B, Mukhamedrakhimov, R., Uvnas-Moberg, K., Widstrom, A-M. (2009). Early contact versus separation: effects on mother-infant interaction one year later. Birth, 36(2), 97–109.

Fahy, K., Saxton, A., Smith, L., & Campbell, F. (2015). Making pronurturance routine care to reduce PPH: Practice development research. Women and Birth, 28, S45. https://doi.org/10.1016/j.wombi.2015.07.144

Fahy, K. M., & Parratt, J. A. (2006). Birth Territory: A theory for midwifery practice. Women Birth, 19(2), 45-50. https://doi.org/10.1016/j.wombi.2006.05.001

Kahalon, R., Preis, H., & Benyamini, Y. (2021). Who benefits most from skin-to-skin mother-infant contact after birth? Survey findings on skin-to-skin and birth satisfaction by mode of birth. Midwifery92, 102862. https://doi.org/10.1016/j.midw.2020.102862

Kemp, J., & Sandall, J. (2010). Normal birth, magical birth: the role of the 36-week birth talk in caseload midwifery practice. Midwifery, 26(2), 211-221. https://doi.org/10.1016/j.midw.2008.07.002

Kirca, N, Adibelli, D. Effects of mother–infant skin-to-skin contact on postpartum depression: A systematic review. (2021). Perspectives in Psychiatric Care. 1– 10.

Mejía Jiménez, I., Salvador López, R., García Rosas, E., Rodriguez de la Torre, I., Montes García, J., de la Cruz Conty, M. L., Martínez Pérez, O., & Spanish Obstetric Emergency Group† (2021). Umbilical cord clamping and skin-to-skin contact in deliveries from women positive for SARS-CoV-2: a prospective observational study. BJOG128(5), 908–915. https://doi.org/10.1111/1471-0528.16597

Saxton, A., Fahy, K., Rolfe, M., Skinner, V. & Hastie, C. (2015). Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage: results of a cohort study. Midwifery, 31(11), 1110-1117. https://doi.org/10.1016/j.midw.2015.07.008

Stevens, J., Schmied,V., Burns, E., & Dahlen, H.G. (2018). Who owns the baby? A video ethnography of skin-to-skin contact after a caesarean section. Women and Birth, 31(6), 453-462. https://doi.org/10.1016/j.wombi.2018.02.005

Thompson, N. M., & Maeder, A. B. (2021). Initiative to increase skin-to-skin contact in the operating room after cesarean. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 50(2), 193–204. https://doi.org/10.1016/j.jogn.2020.10.008

Widström, A. M., Brimdyr, K., Svensson, K., Cadwell, K., & Nissen, E. (2019). Skin-to-skin contact the first hour after birth, underlying implications and clinical practice. Acta Paediatrica108(7), 1192–1204. https://doi.org/10.1111/apa.14754

 

 

Clinical benefits for women who receive continuity from a midwifery student

Students provide continuity for women – regardless of model

Continuity of care, and continuity of carer, are terms which are commonly confused (Donnelly et al., 2019). Continuity of carer means a named designated carer – usually a midwife – provides most of the care to each woman for the antenatal, labour and birth, and postpartum periods (National Perinatal Epidemiology and Statistics Unit, 2015). Australian Bachelor of Midwifery programs require students to provide continuity of carer experiences (CoCE) under the supervision of a midwife. Specifically, students must recruit a minimum of 10 pregnant women –  and then attend at least four antenatal visits, labour and birth, and at least two postnatal visits with each woman. We know that women want and value midwifery students because they provide a familiar face and much needed support, especially in fragmented models of care (Kelly et al., 2014; Tickle et al., 2016; Stulz et al., 2020; Jefford et al., 2020; Tickle et al. 2020). However, new research demonstrates that women may also benefit clinically from having student provide continuity of carer alongside a supervising midwife (Tickle et al., 2021).

Outcomes for women who had continuity from a midwifery student

A recent study looked back at clinical outcomes for women who gave birth in 2015 – 2020 across several maternity services (and models of care), who had received CoCE with a pre-registration midwifery student (Tickle et al., 2021). Midwifery students used a secure electronic portfolio to record the clinical details for their CoCE participants (e.g., gestation at first visit, onset of labour, mode of birth, perineal status). The portfolio data were anonymised to protect confidentiality before they were extracted into a statistical program for analysis. Outcomes for women who had CoCE with a midwifery student were compared with national and state-wide data. The researchers analysed data from over 5000 women during pregnancy, and of those, and over 3000 who had birthed. Women who received CoCE with a midwifery student had clinical outcomes equal to or better than women outcomes in the state of Queensland. Significantly, women had lower rates of tobacco smoking after 20 weeks of pregnancy, episiotomy, and severe perineal trauma (Tickle et al., 2021).

Lower rates of smoking in later stages of pregnancy

A recent systematic review of GPs, midwives, and obstetricians practice found that most asked, advised and assessed pregnant women’s readiness to cease smoking; but were less likely to assist with cessation or arrange referral (Gould et al., 2019). Midwives are particularly effective at helping women stop smoking in late pregnancy (McNeil et al., 2012). Furthermore, there is evidence that women are more likely to cease smoking when they receive consistent information from multiple health providers (An et al., 2008). This may explain why having continuity from a student enhanced women’s ability and willingness to cease smoking during pregnancy.

Lower rates of perineal trauma

Midwifery students who provide CoCE to women are encouraged to be the accoucheur births under supervision. Because evidence-based practice is a founding principle of undergraduate midwifery education, students are prepared to use evidence-based techniques in practice (Australian Nursing and Midwifery Accreditation Council, 2021). For example, antenatal perineal massage or application of warm compresses in second stage labour are both associated with lower rates of episiotomy and several perineal trauma (Tickle et al., 2021).

So…what now?

Continuity is a unique learning opportunity for midwifery students to appreciate maternity care from the woman’s point-of-view. In this way, students learn the importance of woman-centred care (Tickle et al., 2021). Furthermore, continuity provides the optimal context for learning and supervised practice (Tierney et al., 2017). Therefore, continuity of midwifery care from a student alongside a supervising midwife, benefits both the woman and the student. Pregnant women should be aware of the benefits of receiving continuity from a midwifery student – and be able to access this option.

Midwifery programs that provide a secure and practical web-based system for CoCE data collection enable students’ clinical reflection. This process prepares new graduate midwives for ongoing reflexivity and processes including midwifery practice review. Analysis of women’s feedback and outcomes builds the capability of the midwifery workforce to place the woman at the centre of care.

Highlighted research

Tickle, N. Gamble, J., Creedy, D.K. (2021). Clinical outcomes for women who had continuity of care experiences with midwifery students. Women and Birth, Article in Press. https://dx.doi.org/10.1016/j.wombi.2021.04.004

References 

Australian Nursing and Midwifery Accreditation Council. (2021). Midwife accreditation standards 2021. ANMAC https://www.anmac.org.au/sites/default/files/documents/06920_anmac_midwife_std_2021_online_05_fa.pdf

Donnolley, N. R., Chambers, G. M., Butler-Henderson, K. A., Chapman, M. G., & Sullivan, E. (2019). A validation study of the Australian Maternity Care Classification System. Women and Birth, 32(3), 204-212. https://doi.org/10.1016/j.wombi.2018.08.161

Gould, G. S., Twyman, L., Stevenson, L., Gribbin, G. R., Bonevski, B., Palazzi, K., & Bar Zeev, Y. (2019). What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis. British Medical Journal Open, 9(8), e026037. https://doi.org/10.1136/bmjopen-2018-026037

Jefford, E., Nolan, S., Sansone, H. & Provost, S. (2020). ‘A match made in midwifery’: Women’s perceptions of student midwife partnerships”. Women and Birth, 33(2), 193-198. https://doi.org/10.1016/j.wombi.2018.11.018

Kelly, J., West, R., Gamble, J., Sidebotham, M., Carson, V., & Duffy, E.  (2014). ‘She knows how we feel’: Australian Aboriginal and Torres Strait Islander childbearing women’s experience of continuity of care with an Australian Aboriginal and Torres Strait Islander midwifery student. Women and Birth, 27(3), 157-162. https://doi.org/10.1016/j.wombi.2014.06.002

McNeill, J., Lynn, F., & Alderdice, F. (2012). Public health interventions in midwifery: a systematic review of systematic reviews. BMC Public Health, 12(1), 955. https://doi.org/10.1186/1471-2458-12-955

National Perinatal Epidemiology and Statistics Unit. (2015). Maternity model of care—extent of continuity of carer, code N[N]. Retrieved from: https://meteor.aihw.gov.au/content/index.phtml/itemId/562423

Stulz, V., Elmir, R, & Reilly, H. (2020). Evaluation of a student-led midwifery group practice: A woman’s perspective. Midwifery, 86. https://doi.org/10.1016/j.midw.2020.102691

Tickle, N., Sidebotham, M., Fenwick, J., & Gamble, J. (2016). Women’s experiences of having a Bachelor of Midwifery student provide continuity of care. Women and Birth, 29(3), 245-251. https://doi.org/10.1016/j.wombi.2015.11.002

Tickle, N., Gamble, J., & Creedy, D.K. (2020). Women’s reports of satisfaction and respect with continuity of care experiences by students: Findings from a routine, online survey. Women and Birth. (20), 30377-2. https://doi.org/10.1016/j.wombi.2020.11.004

Tierney, O., Sweet, L., Houston, D., & Ebert, L. (2017). The continuity of care experience in Australian midwifery education—What have we achieved? Women and Birth, 30(3), 200-205. https://doi.org/10.1016/j.wombi.2016.10.006

 

 

 

 

 

 

 

 

 

“Caesareans are just another way of giving birth” – right?

Caesarean section (CS) is common in high income-countries. In Australia, 35% of women give birth by caesarean, while 85% of women with a previous CS will have a repeat CS (AIHW, 2020a). However, there is increasing media interest in the concept of ‘caesarean shaming’ or ‘caesarean stigma’. Although shame is an emotion of self-blame (Heshmat, 2015), a recent media article has suggested that talking about risks of CS and benefits of normal birth, causes women who have experienced or are planning CS, to feel shame (Begg, 2021) https://www.mamamia.com.au/c-section-shaming-stories/. However, caesarean shaming is not born out in the literature – and focus on it obfuscates the issues.

Research on caesarean shaming or stigma

A quick literature search finds just two articles on CS shaming or stigma  – one is a research paper. A UK study presents results from 75 semi-structured interviews with women on a postnatal ward following a planned or unplanned CS (Tully & Ball, 2013). While some women felt stigma that they had “copped out of normal birth”; none of the women referred to feeling shamed by their decision or experience (Tully & Ball, 2013). The recent media article quotes 30 Australian women who uniformly believed their CS was lifesaving (Begg, 2021). Importantly, this echoes the UK interview results –every woman considered that her CS had been justified and necessary. Women commonly perceived it was their only option and lifesaving (Tully & Ball, 2013).

Caesareans can be life-saving but…this is epidemic

Caesarean section rates above 15% do not reduce maternal or neonatal mortality rates (Gibbons et al., 2010). Indeed, in high-income countries maternal death is exceedingly rare – 5.5 per 100,000  women who give birth in Australia will die (AIHW, 2020b). Maternity health professionals (WHO, 2018) and maternity consumer organisations (MCA, 2021) are increasingly concerned that CS is being performed without a medical or obstetric indication. Subsequently, we are experiencing a “caesarean epidemic” in high-income countries (Visser et al. 2018) – this is the story that needs to be picked up by the media.

Unnecessary caesarean creates harm without benefit

When a CS occurs without benefit, it creates unnecessary risks for mother and baby (Wise, 2018) . However, this jars with the commonly held view that CS is safer than vaginal birth because it is more “controlled” (Coates et al, 2021b).

Women who have a CS are at increased risk of birth trauma, uterine rupture, death, and future pregnancy complications including miscarriage, ectopic pregnancy, preterm birth, and stillbirth (Sandall et al., 2018). Babies born via CS have higher rates of nursery admission and lower chance of sustained breastfeeding with negative health consequences (Hobbs et al., 2016). While evidence about long-term risks for CS born children continues to emerge, they appear to include allergies and asthma; diabetes, gastroenteritis, obesity, autism, and attention deficit/hyperactivity disorder (Sandall et al., 2018; Słabuszewska-Jóźwiak et al., 2020; Zhang et al., 2019).

Early term caesarean carries additional risks

The recent Australian Commission for Safety and Quality in Healthcare report showed that 50% of CS performed before 39 weeks gestation were done without a medical indication (ACSQH, 2021). Worryingly, early planned birth (<39 weeks) increases risks for babies of breathing difficulties, admission to neonatal nursery (ASQH, 2021), and in rare instances neonatal death (Prediger et al., 2020). In addition, the long-term risks of early planned birth are learning difficulties and attention deficit hyperactivity disorder (ACSQH, 2021).

How do women make informed decisions about caesarean

The Federation of International Gynecologists and Obstetricians have released a statement that women must be “properly informed” of the risks prior to consenting for CS (Visser et al., 2018). Coates et al. (2021a) survey of Australian women’s decision-making around planned CS reported that 90% perceived they had adequate information that they understood, including risks and benefits of CS. However, 15% felt pressured or uncertain about their decision, a figure reflected in the wider literature (Coates et al., 2021a). Further research on women’s decision-making about planned birth (either induction or CS) indicates that approximately:

  • 4 in 10 women were not provided with written information before deciding
  • 1 in 5 women felt they “didn’t really have a choice” about induction or CS (Coates et al., 2021b).

What can maternity services do

Facilitating informed decision-making is part of addressing alarming rates of CS. Likewise, it may be necessary to focus on changing the maternity care system. For example, there are several system-wide strategies that have been demonstrated to reduce CS rates:

  • Providing women with continuity of midwifery care (Callander et al., 2019)
  • Benchmarking, auditing and publishing CS rates in health services (Chen et al., 2018; Visser et al., 2018)
  • Funding models that mean fees for vaginal birth and CS are the same (Visser et al., 2018)
  • Implementation of guidelines, combined with mandatory second obstetric opinion about indication for CS, and physician education (Chen et al., 2018).

Additionally, it may be useful for clinicians to reflect on how they debrief with women following a CS, especially in relation to a possible future pregnancy. For example, considering how language may be interpreted (i.e., my baby almost died) and resisting the impulse to reassure women their CS was warranted if the clinical picture and evidence suggests it was not, is important (Niemczyk, 2014).

References

Australian Institute of Health and Welfare. (2020a). Australia’s mothers and babies 2018—in brief. Canberra: AIHW.

Australian Institute of Health and Welfare. (2020b). Maternal deaths in Australia. Retrieved from https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-in-australia

Australian Commission on Safety and Quality in Healthcare. (2021).
The Fourth Australian Atlas on Healthcare Variation. Retrieved from: https://www.safetyandquality.gov.au/our-work/healthcare-variation/fourth-atlas-2021/early-planned-births

Begg, C. (2021). “I was told I had taken the easy way out.” We need to talk about C-section shaming. Mamamia. https://www.mamamia.com.au/c-section-shaming-stories/

Callander, E., Creedy, D.K., Gamble, J., Fox, H., Toohill, J., Sneddon, A., & Ellwood D. (2019). Reducing caesarean section: An economic evaluation of routine induction of labour at 39 weeks gestation in low-risk nulliparous women. Paediatric and Perinatal Epidemiology, 34(1), 3-11.

Chen I, Opiyo N, Tavender E, et al. (2018). Non-clinical interventions for reducing unnecessary caesarean section. The Cochrane Database of Systematic Reviews, 9(9): Cd005528.

Coates, D., Donnolley, N., Thirukumar, P., Lainchbury, A., Spear, V., & Henry, A. (2021a). Women’s experiences of decision-making and beliefs in relation to planned caesarean section: A survey study. The Australian & New Zealand Journal of Obstetrics & Gynaecology61(1), 106–115. https://doi.org/10.1111/ajo.13255

Coates, D., Donnolley, N., Foureur, M., Thirukumar, P., & Henry, A. (2021b). Factors associated with women’s birth beliefs and experiences of decision-making in the context of planned birth: A survey study. Midwifery96, 102944. https://doi.org/10.1016/j.midw.2021.102944

Gibbons L, Belizán JM, Lauer JA, et al. (2010). The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. World Health Rep, 30, 1–31.

Heshmat, S. (2015). Five factors that make you feel shame. Psychology Today. https://www.psychologytoday.com/us/blog/science-choice/201510/5-factors-make-you-feel-shame

Hobbs, A.J., Mannion, C.A., McDonald, S.W., Brockway, M., Tough, S.C. (2016). The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. BMC Pregnancy and Childbirth, 16, 90.

Independent Hospital Pricing Authority. (2020). National Hospital Cost Data Collection, Round 22 (2017-18). Sydney: IHPA.

Maternity Choices Australia. (2021). 2021 Federal Election MP/Senator brief endorsed by 15 community organisations. Retrieved from https://www.maternitychoices.org/advocacy

Niemczyk, N. A. (2014). Most women think their cesarean birth was necessary. Journal of Midwifery and Women’s Health, 59, 363-364.

Prediger, B., Mathes, T., Polus, S., Glatt, A., Bühn, S., Schiermeier, S., Neugebauer, E., & Pieper, D. (2020). A systematic review and time-response meta-analysis of the optimal timing of elective caesarean sections for best maternal and neonatal health outcomes. BMC Pregnancy and Childbirth20(1), 395. https://doi.org/10.1186/s12884-020-03036-1

Sandall J, Tribe RM, Avery L, et al. (2018). Short-term and long-term effects of caesarean section on the health of women and children. The Lancet, 392(10155),1349-57.

Słabuszewska-Jóźwiak, A., Szymański, J. K., Ciebiera, M., Sarecka-Hujar, B., & Jakiel, G. (2020). Pediatrics consequences of caesarean section-A systematic review and meta-analysis. International Journal of Environmental Research and Public Health17(21), 8031. https://doi.org/10.3390/ijerph17218031

Tully, K. P., & Ball, H. L. (2013). Misrecognition of need: women’s experiences of and explanations for undergoing cesarean delivery. Social Science & Medicine, 85(1982), 103–111. https://doi.org/10.1016/j.socscimed.2013.02.039

Visser, G.H.A, Ayres-de-Campos, D., Barnea, E.R, et al. (2018). FIGO position paper: how to stop the caesarean section epidemic. The Lancet, 392(10155), 1286-1287.

Wise, J. (2018). Alarming global rise in caesarean births, figure show. British Medical Journal, 363, 4319.

World Health Organization. (2018). WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections. Geneva: WHO.

Zhang T, Sidorchuk A, Sevilla-Cermeño L, et al. (2019). Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring. JAMA Network Open, 2(8), e1910236.

 

The transformative power of birth

Induction of labour, epidural analgesia, and caesarean section are now common themes in many women’s birth stories. Women are often fearful of childbirth which may drive them to seek out medical intervention without a medical reason (Nilsson et al., 2018). Indeed, fragmented hospital maternity care supports the view that pregnancy and birth are inherently dangerous and require management and control. From this perspective, labour pain is viewed as needing ‘relief’ and the use of epidural analgesia is seen as normal practice (Newnham, McKellar, & Pincombe, 2016). The community generally lack knowledge about normal birth and in particular, the benefits of physiological birth (Wong, He, Shorey, & Koh, 2017). However, having a vaginal birth with minimal interference has considerable benefits for women and their babies in both the short and long term.

Birth is a process best supported by a known and trusted midwife

Birth is a normal and deeply significant psychological and social event in a woman’s life – and in most instances does not require medical rescue or relief. Further, there is considerable evidence that birth is best supported by a known midwife who provides reassurance, nurturing and comfort (Walsh, 2006), so that a woman can work with pain rather than resist it (Leap, Sandall, Buckland, & Huber, 2010), and feel safe enough to ‘let go’ (Anderson, 2000). When women are supported in this way, birth has the potential to be positively transformative, producing a sense of inner strength, triumph, and bliss. These transformative experiences have a lasting impact on the woman’s sense of self (Schwartz et al 2015), confidence as a new mother (Fenwick et al 2015), and relationship with her newborn (Toohill et al 2014).

New theory explains the positive potential of birth-giving

While the subject of birth trauma is gaining traction, women’s potential to positively transform through birth is not well understood. New research has addressed this gap and developed new language that can facilitate women’s conversations about their experiences. PhD candidate Ella Kurz applied feminist theory to childbirth to develop a theory that explains the transformative power of giving birth (Kurz, Davis & Browne, 2021).

The new theory, Parturescence, describes the process of women ‘becoming’ through childbirth (Kurz et al., 2021). Positive transformation results in better psycho-social well-being after birth. Whereas negative transformation includes birth trauma and psychological injury following birth. Parturescence theory refers to lines of descent (activities that bring predictability and control in birth) and lines of ascent (activities which open new ways of thinking and being). Importantly, the challenging and destabilising parts of labour and birth – and how these are mediated by maternity care – are key to women’s positive or negative transformation (Kurz et al., 2021). Midwife-woman interactions can facilitate negative or positive transformation through birth (Kurz et al., 2021). Midwives need to have the motivation and capacity to support women to feel safe, loved, relaxed and unafraid during birth – but not all midwives behave this way (Allen, Kildea, Hartz, Tracy, & Tracy, 2017). Recent research has demonstrated the importance of midwives’ social and emotional competence to establish and maintain positive relationships (Hastie & Barclay, 2021).

What does this mean for women and maternity services?

Birth has intrinsic value for women and their babies – and this should be reflected in how maternity care is organised and provided. Women and the wider community should know that women benefit from the continuous supportive presence of a known and trusted midwife who can hold the space while they transform triumphant into motherhood. Importantly, when women are treated with respect and compassion, regardless of mode of birth, there is potential for positive transformation.

Highlighted research

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

References

Allen, J., Kildea, S., Hartz, D. L., Tracy, M., & Tracy, S. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148-156. https://doi.org/10.1016/j.midw.2017.03.012

Anderson, T. (2000). Feeling safe enough to let go: the relationship between a woman and her midwife during the second stage of labour. In M. Kirkham (Ed.), The Midwife–Mother Relationship. Macmillan Press.

Fenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, Scuffham PA, & Ryding EL. (2015). Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and psychological well-being. BMC Pregnancy & Childbirth, 15, 284. https://doi.org/10.1186/s12884-015-0721-y

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery. https://doi.org/10.1016/j.midw.2021.102997

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

Leap, N., Sandall, J., Buckland, S., & Huber, U. (2010). Journey to Confidence: Women’s Experiences of Pain in Labour and Relational Continuity of Care. Journal of Midwifery & Women’s Health, 55(3), 234-242. https://doi.org/10.1016/j.jmwh.2010.02.001

Newnham E., McKellar L., & Pincombe, J. (2016). A critical literature review of epidural analgesia. Evid Based Midwifery, 14(1), 22-28.

Nilsson, C., Hessman, E., Sjöblom, H., Dencker, A., Jangsten, E., Mollberg, M., . . . Begley, C. (2018). Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth, 18(1), 28. https://doi.org/10.1186/s12884-018-1659-7

Schwartz L, Toohill J, Creedy DK, Baird K, Gamble G & Fenwick J. (2015) Factors associated with childbirth self-efficacy in childbearing women. BMC Pregnancy and Childbirth, 15:29.

Wong, C. Y. W., He, H. G., Shorey, S., & Koh, S. S. L. (2017). An integrative literature review on midwives’ perceptions on the facilitators and barriers of physiological birth. International Journal of Nursing Practice, 23(6). https://doi.org/10.1111/ijn.12602

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.