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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

 

 

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