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Do soft fairy lights matter during birth? An opinion piece

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

Do soft fairy lights matter?

There is an increasing interest in women customising and changing their birthing environments by adding such things as candles, fairy lights, and motivational posters to make the space their own.  In addition, we are seeing more consumer demand for birthing rooms that feel less like a hospital room and more like a hotel or home environment.  But does the birthing environment actually matter? Are there environments that promote normal physiological birth?  Does creating a birth environment that feels safe and secure to the woman affect outcomes?  Do midwives have a role in facilitating this?

Modern day Australia says the birth environment doesn’t matter…

Generally speaking, modern day, mainstream Australia doesn’t value the birth environment and its effect on birth.  Research shows that women who want to engage in changing their birth environment – having music, candles, and the room dimly lit – are often received with disrespect and perceived to be controlling by the general public. Birth stories are told and passed down through generations, shared between friends over coffee, and often focus more on the negative than the positive. Any pregnant woman will tell you that unsolicited labour and birth horror stories start the moment her pregnancy is public. The main storyline? It’s terrifying. It is rare to hear of women birthing at home, with very few publicly funded home birth options available.  While this is slowly changing, the norm is still a hospital birth, under the care of an obstetrician, with midwives providing care during labour and birth.

Has birth become over-medicalised?

In the 18th century most women gave birth in their own home, with a midwife in attendance, surrounded by female family members.  Yet currently in Australia, 96% of women birth in a hospital, with less than 4% birthing at home, in a birth centre or before arrival at hospital.  Australia, like most developed countries, is over-medicalised and operates from a bio-medical model of care (Germov, 2014).  This bio-medical model looks primarily at physical illness and focuses on diagnosis and treatment.  Over-medicalisation and the biomedical model is a widely accepted norm in western societies and which regards pregnancy and birth in the same way: diagnosis (pregnancy) and treatment (delivery of the baby) (Germov, 2014).  Over the last one hundred or so years, birth has slowly been taken out of the community and put into the medical model.  This process, of separating the woman from her own home and familiar environment, and surrounding her with strangers and technology at such an intimate and private time, has only worked to de-humanise birth.

Most Australians, in most circumstances, submit to this medical model, leaving power in the hands of doctors and medical practitioners, and holding them as the ultimate experts.  This medicalised model places an emphasis on risk, and a pressure to conform and accept the environment.  Midwives are required to be the guardians that facilitate this birth environment.

What does media tell us about birth?

Not surprisingly, the media portrays childbirth as a painful, dramatic, and distressing experience.  Women are rarely seen off the bed, and doctors are seen as the experts who arrive in just time to “deliver” the woman from this difficult situation.  A birth room analysis study, completed in 2015, collected images from Google, Wikipedia etc. of midwifery units in developed countries to ascertain the message being sent about labour rooms.  While three primary categories were identified; the technological, the home-like and the hybrid domesticated birth room, the dominant was the technological birth room.  This type of room pictured the bed in the centre, surrounded by medical equipment.  The message? Birth is risky and dangerous and you need this technological environment to give birth.  One needs to ask: What does this do to the woman? How does it make her feel?

As identified earlier, the media plays a role in framing birth for the general public (Germov, 2014).  In 2014, a survey of young Australian women who had no children, highlighted that a disproportionate number of births on TV showed disasters and emergency situations.  However, the landscape has changed since the advent of social media sites, with many traditional media trying to adapt over the last decade.  With the advent of social media, streaming sites, and a plethora of podcasts, different types of birth stories are being told and seen.  More stories of women birthing at home or in a birthing pool, in a birth centre and stories of women owning their birth space are emerging.

Tell me about the hormones…

Physiology teaches us about the way the body works: that oxytocin, what we call the “love” hormone, is needed for the uterus to contract, and labour to continue.  In fact it is a manufactured oxytocin that is often given to women to induce or speed up a slow labour (Stables & Rankin, 2010).  Oxytocin is released into the brain as a result of a stimulus, such as social contact, physical touch, or skin to skin contact (Stables & Rankin, 2010).  When we are fearful, our ‘fight or flight’ reaction kicks in, releasing adrenaline into our system.  This disrupts the production of oxytocin and interferes with labour (Stables & Rankin, 2010).  Research has shown that the ideal birthing space is a sanctum in which women feel they have privacy, and are at ease and comfortable. This comfort is key for optimum physiological function and for women’s emotional wellbeing during labour and birth.  Birth room surveillance, and use of high technology, has been shown to increase stress for women; and may continue to cause a cascade of hormonal imbalances that have negative consequences.  As identified earlier, the increase in adrenaline results in a decrease in oxytocin; slowing down labour.  Additionally, the vasoconstrictive effect of adrenaline may divert blood from the placenta, which can lead to a decrease in fetal oxygenation and therefore fetal distress.

Women need to feel safe and secure in labour and birth to have that natural increase in oxytocin and encourage physiologic birth.  The Room4birth study currently being undertaken in Sweden, allocates women in spontaneous labour to either a standard medicalised room or a newly designed birthing room that can be adapted to the woman’s desires (lights, media installation, silencer, bathtub).  The study will measure physical outcomes as well as women’s experiences.  In addition, another study on the effects of the birthing room is currently being undertaken in Germany, again assessing physical outcomes and maternal satisfaction.

What do midwives say…?

Midwives know that to facilitate normal, physiological birth they influence the birth environment to create a safe and private space.  While home is cited as the ideal place for normal birth, hospital birthing rooms can be designed and adapted to create a home-like environment that is low tech. Midwives believe it is part of their role to guard the space for women, not just physically but emotionally too,  particularly in a bio-medical model that emphasises risk and where surveillance is commonplace.

Midwives consider a supportive environment to be critical and of paramount importance to facilitating a physiologically normal birth.  Dim lighting, a quiet space, and limiting people coming in and out of the room are all considered important in creating this intimate space.  Additionally, midwives often consider themselves protectors of this space and an emotional support for the woman and her family, while encouraging mobility and movement.  Midwives are not only best placed to educate and inform women about their rights and the benefits of creating such a space, and are well placed to protect this birthing space physically and emotionally, it is also part of their professional obligation.

But what about…?

The question is often asked – what about women who have their babies on the side of the road? Or during natural disasters? In situations where they don’t feel safe?  This is the wrong question to ask, because it dismisses women’s right for birthing in an environment that they feel comfortable, private and secure in.  These situations are rare and extreme, and preclude any control of the environment.  Because women can and do give birth in stressful and traumatic situations does not negate the fact that women have the choice to change and alter their birth environment.  While more research should be undertaken for women birthing in these emergency situations, it does not negate what we already know about the effect of hormones and environment on labouring women.

Birth environment does matter

Current research shows that the birthing environment does matter, and that, to increase the chance of a physiologically normal birth, women need to feel safe and secure.  Research also shows that women reported greater satisfaction with care and a decrease in pain intensity after birthing rooms had been redesigned. Women should be encouraged to take control of their birthing environments, to do what they need in order to create a space that feels peaceful, secure and safe.  That space will look different for each woman and may well include fairy lights!

References

Australian Institute of Health and Welfare. (2018). Australia’s mothers and babies data visualisations https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-data-visualisations/contents/labour-and-birth/place-of-birth

Ayerle, G. M., Schäfers, R., Mattern, E., Striebich, S., Haastert, B., Vomhof, M., Icks, A., Ronniger, Y., & Seliger, G. (2018). Effects of the birthing room environment on vaginal births and client-centred outcomes for women at term planning a vaginal birth: BE-UP, a multicentre randomised controlled trial. Trials, 19(1), 641-613. https://doi.org/10.1186/s13063-018-2979-7

Berg, M., Goldkuhl, L., Nilsson, C., Wijk, H., Gyllensten, H., Lindahl, G., Uvnäs Moberg, K., Begley, C., Göteborgs, u., Gothenburg, U., Centrum för personcentrerad vård vid Göteborgs, u., Sahlgrenska, A., Sahlgrenska, a., University of Gothenburg Centre for person-centred, c., Institutionen för vårdvetenskap och, h., Institute of, H., & Care, S. (2019). Room4Birth – the effect of an adaptable birthing room on labour and birth outcomes for nulliparous women at term with spontaneous labour start: study protocol for a randomised controlled superiority trial in Sweden. Trials, 20(1), 629-612. https://doi.org/10.1186/s13063-019-3765-x

Bowden, C., Sheehan, A., & Foureur, M. (2016). Birth room images: What they tell us about childbirth. A discourse analysis of birth rooms in developed countries. Midwifery, 35, 71-77. https://doi.org/10.1016/j.midw.2016.02.003

Butler, M. M. (2017). Exploring the strategies that midwives in British Columbia use to promote normal birth. BMC Pregnancy and Childbirth, 17(1), 168-112. https://doi.org/10.1186/s12884-017-1323-7

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

D’Cruz, L., & Lee, C. (2014). Childless expecttions: an Australian study of young childless women. Journal of Reproductive and Infant Psychology, 32(2), 199-211. https://doi.org/10.1080/02646838.2013.875134

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

Foureur, M., Davis, D., Fenwick, J., Leap, N., Iedema, R., Forbes, I., & Homer, C. S. E. (2010). The relationship between birth unit design and safe, satisfying birth: Developing a hypothetical model. Midwifery, 26(5), 520-525. https://doi.org/10.1016/j.midw.2010.05.015

Germov, J. (2014). Second Opinion: An Introduction to Health Sociology (5th ed.). Oxford University Press.

Happel-Parkins, A., & Azim, K. A. (2016). At pains to consent: A narrative inquiry into women’s attempts of natural childbirth. Women and Birth, 29(4), 310-320. https://doi.org/10.1016/j.wombi.2015.11.004

Moscucci, O. (1993). The Science of woman: Gynaecology and Gender in England, 1800 – 1929. https://books.google.co.uk/books?id=szmnVZs_ImsC&pg=PA42&source=gbs_toc_r&hl=en – v=onepage&q&f=false

Nusing and Midwifery Board of Australia. (2018). Midwife Standards for Practice. https://doi.org/https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/Midwife-standards-for-practice.aspx

Seibold, C., Licqurish, S., Rolls, C., & Hopkins, F. (2010). ‘Lending the space’: Midwives perceptions of birth space and clinical risk management. Midwifery, 26(5), 526-531. https://doi.org/10.1016/j.midw.2010.06.011

Stables, D., & Rankin, J. (2010). Physiology in Childbearing with Anatomy and Related Biosciences (3rd Edition ed.). Elsevier Limited.

Stenglin, M., & Foureur, M. (2013). Designing out the fear cascade to increase the likelihood of normal birth. Midwifery, 29(8), 819-825. https://doi.org/10.1016/j.midw.2013.04.005

Wagner, M. (2001). Fish can’t see water: the need to humanize birth. International Journal of Gynaecology and Obstetrics, 75 Suppl 1, S25. https://birthinternational.com/article/birth/fish-cant-see-water/

Welbers, K., & Opgenhaffen, M. (2018). Social media gatekeeping: An analysis of the gatekeeping influence of newspapers’ public Facebook pages. New Media & Society, 20(12), 4728-4747. https://doi.org/10.1177/1461444818784302

 

Optimising infant gut health in midwifery practice: An opinion piece

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

Optimising infant gut health in midwifery practice: An opinion piece

Women are becoming increasingly aware of the importance of their baby’s gut health. Asthma, allergies, diabetes type 2, inflammatory bowel disease, obesity and cancer are on a growing list of chronic illnesses linked to disruptions of the gut microbiota (Azad et. al., 2013). The benefits of probiotics and prebiotics in infant and toddler formulas are heavily promoted by advertisers persuading parents to buy their products. Microbiota Transfer Therapy (MTT) has recently been found to improve autism symptoms (Kang, et. al., 2019). This treatment involves the transfer of faecal bacteria and microbes from a healthy individual to another person to improve their depleted gut microbiome.

How science is changing our approach health and chronic diseases

Many parents are unaware of how the mode of birth plays a vital part in establishing a healthy gut microbiome. Babies born vaginally have a gut microbiome akin to their mother’s vaginal and faecal flora. This transfer occurs as the baby passes through the birth canal absorbing the mother’s microbes. (Azad et. al., 2013; Dominguez-Bello et. al., 2010; Dunn et al., 2017; Yang, et. al., 2016).

In contrast, babies born by planned c-sections develop a gut microbiome that resembles the mother’s skin flora and microbes in the hospital environment (Dominguez-Bello et. al., 2010). This is because the baby’s first points of contact are the mother’s skin and the surfaces and air in the operating theatre in the moments following birth. Babies born by caesarean section are extracted from a relatively sterile womb therefore avoiding exposure to the birth canal and the mother’s microbiota (Mueller et. al., 2019). Babies born by unplanned caesarean section fare a little better, acquiring more bacterial abundance and diversity than those born by planned caesarean section. Babies born after unplanned caesarean section had a similar microbiome to vaginally born babies (Azad, et. al., 2013), suggesting that some microbe transfer from the mother to baby occurs during the labour process.

As the rates of caesarean sections continue to rise across the globe, information sharing with parents about the potential impacts this form of birth on the baby’s gut microbiome is important. Other interventions are also commonly used during birth such as: the use of antibiotics, vaginal examinations, and artificial rupturing of the membranes (Johansson et. al., 2012; Yang et. al., 2016). These too can disrupt the baby’s gut microbiome.

The human microbiome is a new field of research…

Midwives need to be informed about the latest research and be confident to educate parents about the impact of the mode of birth on their baby’s gut microbiome. This is no easy feat considering the flood of evidence recently published on the topic (Lokugamage & Pathberiya, 2019). To provide some perspective, very little was known about human microbiome before April 2003 when the human genome was first sequenced (National Human Genome Institute, 2020). Since then, the science has grown exponentially and there remains much yet to be understood. But what we do know is that preventative health approaches will be the way of the future for eliminating chronic disease (Lewis et. al., 2020). Midwives in continuity of care models are ideally placed to maximise this opportunity as part of woman-centred care. This requires a great deal of open mindedness, continuous learning, and expansion in practice.

Vaginal seeding as prevention during planned caesarean sections

Vaginal seeding is a preventative intervention to help counter a baby’s compromised microbiome after a caesarean section. It involves the swabbing of the baby’s face, mouth, and nose with secretions from the mother’s vagina immediately after birth. Growing awareness of the benefits of healthy gut bacteria for newborn infants has parents demanding vaginal seeding as part of planned caesarean section (Wissemann, 2018). The feature-length documentary Microbirth was a powerful film which showed the microscopic world of microbes and how seeding takes place around the time of birth. The short and long-term effects of changes in the newborn’s microbiome are explored in the film along with the implications of altered microbiomes on the health of future generations. This documentary did much to raise public awareness about the importance of the human microbiome for health (Harman & Wakeford, 2014).

Vaginal seeding can modify the baby’s microbial composition which may help override the disturbance caused by  caesarean section (Dominguez-Bello et. al., 2010). To date only one pilot study has investigated the efficacy of this intervention. Although the sample group was very small (four babies), within the first week of life the results showed these babies had developed microbiomes that compared to babies born vaginally (Wissemann, 2018). Although the seeded microbiomes were only partially restored, the results were promising. Clearly, more research into this intervention is needed before it can be implemented into clinical practice on a wide scale.

The information age

The deluge of information available means healthcare is becoming increasingly consumer driven. This is not a bad thing. Consumer involvement helps to move our health systems in the right direction. Public access to science journals means astute parents have more information at their fingertips about health than ever before. Well informed parents can leave doctors and midwives underprepared when asked about vaginal seeding for a planned caesarean. The lag in time between the announcement of an exciting new discovery and the reality of its safe introduction into practice often means consumer expectations are way ahead of practice.

Midwives may serve women better by promoting normal birth as the preferred option for protecting a baby’s microbiome when a planned caesarean section is negotiable. Supporting and encouraging women to birth vaginally, followed by immediate skin to skin and early breastfeeding, is the ideal for establishing a baby’s healthy gut microbiome.

Home is where the good bacteria live

There is also strong evidence to support home as the optimal birth environment for protecting a newborn’s microbiome. Every person has a unique microbial thumb print which transfers to our living environments. Skin shedding, respiratory activity and skin to surface contact permeates our habitats with our unique flora. This creates microbial diversity within our homes which effects immune defence and disease transfer among the inhabitants. People who live together share the same microbiome (Lax et. al, 2014). A baby born at home is entering an environment where there is already a shared microbiome established. This is in direct contrast to clinical environments which expose a baby to unfamiliar microbes which can be very harmful to health.

Vaginal seeding… is it safe?

Concerns about infectious diseases are at the centre of the argument against vaginal seeding. Chlamydia, HIV, group B streptococci (GBS) and bacterial vaginosis are among the pathogens under the spotlight (Haahr et. al., 2017). The Royal Australian College of Obstetricians and Gynaecologist [RANZCOG] (2016) offers scant information about vaginal seeding. Instead it refers to a British Medical Journal [BMJ] article (Haahr et. al., 2017) via a link for those seeking further information. The BMJ article does not recommend the practise of vaginal seeding in maternity wards. The Danish Society of Obstetrics and Gynaecology’s stance strongly opposes the intervention, highlighting significant risks to babies exposed to GBS and those less than 37 weeks gestation. Early skin to skin to encourage breastfeeding is recommended which is said to “indirectly” boost beneficial gut microbiota (Haahr et. al., 2017, p. 3).

There is notable hesitance from RANZCOG to formalise an opinion about the safety of vaginal seeding. This ambivalence is highlighted in the infection argument with a suggestion that all vaginal births are inherently risky due to inadvertent exposure to pathogens. A hint of resignation is evident in the conclusion which states that the risk associated with vaginal seeding is “probably very low, but in contrast to vaginal birth, vaginal seeding is not a natural process” (Haahr et. al., 2017, p. 3).

So how does a midwife approach vaginal seeding in practice?

The best option to addressing the ongoing debate and controversy surrounding vaginal seeding is to bring it into a women-centred framework. Discussions with women about the general risks associated with caesarean section should also include the changes to the baby’s gut microbiome and the possible long-term effects this can have on immunity and health. It is appropriate to share this information in order to ensure women are supported in the informed decision making process. Health institutions and their employees are not under any obligation to provide vaginal seeding as part of their maternity services. However, conversations should take place with parents about the current evidence. Furthermore, there should be no overt or covert obstructions from doctors or midwives for parents who do wish to practise vaginal seeding independently (Lokugamage, & Pathberiya, 2019).

Thinking outside the square

The World Health Organisation states that caesarean sections are medically necessary in 10 to 15% of cases. However, in Brazil over 60% of babies are now born by caesarean section. This is a global trend and it is not sustainable (Mueller, et. al, 2019). In fact, it is vital to robustly challenge the rising rate as the evidence increasingly shows the long-term damage we are inflicting on the health of future generations. The science behind the human microbiome may well be in its infancy but it offers hope for the rebirth of normal birth.

References

Azad, M., Konya T., Maughan, D., Guttman, C., Field, R., Chari, M., Sears, A., Becker, J., Scott, A. & Kozyrskyj. (2013). Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. Canadian Medical Association Journal, 185(5), 385-394. https://www-ncbi-nlm-nih-gov.libraryproxy.griffith.edu.au/pmc/articles/PMC3602254/?tool=pmcentrez&report=abstract

Dunn, A., Jordan, S., Baker, B. & Carlson, N. (2017). The maternal infant microbiome: Considerations for labor and birth. The American Journal of Maternal/Child Nursing, 42(6), 318–325. https://oce-ovid-com.libraryproxy.griffith.edu.au/article/00005721-201711000-00003/HTML

Dominguez-Bello, M., Costello, E., Contreras, M., Magrisd, M., Hidalgod, G., Fierere, N.& Knight, R. (2010). Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences of the United States of America, 107(26), 11971-11975. https://www-ncbi-nlm-nih-gov.libraryproxy.griffith.edu.au/pmc/journals/2/

Haahr, T., Glavind, J., Axelsson, P., Bistrup Fischer, M., Bjurström, J., & Andrésdóttir, G. et al. (2017). Vaginal seeding or vaginal microbial transfer from the mother to the caesarean-born neonate: a commentary regarding clinical management. BJOG: An International Journal of Obstetrics & Gynaecology, 125(5), 533-536. https://doi.org/10.1111/1471-0528.14792

Harman, T. & Wakeford, A. (2014). Microbirth. Alton Film Production. www.microbirth.com

Johansson M., Saghafian-Hedengren S., Haileselassie, Y., Roos, S., Troye-Blomberg, M., Nilsson, C. & Sverremark-Ekström, E. (2012). Early-life gut bacteria associate with IL-42, IL-102 and IFN-c production at two years of age. PLoS One, 7(11), e49315. https://search-proquest-com.libraryproxy.griffith.edu.au/docview/1326742861/fulltextPDF/F5F59B02EE29464APQ/1?accountid=14543

Kang, D., Adams, J., Coleman, D., Pollard, E., Maldonado, J., McDonough-Means, S., Gregory Caporaso, J., Krajmalnik-Brown, R. (2019). Long-term benefit of Microbiota Transfer Therapy on autism symptoms and gut microbiota. Scientific Reports, 9(1), 1-9. https://search-proquest-com.libraryproxy.griffith.edu.au/docview/2206214105?pq-origsite=summon

Lax, S., Smith, D., Hampton-Marcell, J., Owens, S., Handley, K., Scott, N., Gibbons, S., Larsen, P., Shogan, B., Weiss, S., Metcalf, J., Ursell, L., Vázquez-Baeza, Y., Van Treuren, W., Hasan, N., Gibson, M., Colwell, R., Dantas, G., Knight, R. & Gilbert, J. (2014). Longitudinal analysis of microbial interaction between humans and the indoor environment. American Association for the Advancement of Science, 345(6200), 1048-1052. https://science-sciencemag-org.libraryproxy.griffith.edu.au/content/sci/345/6200/1048.full.pdf

Lewis, C., Obregón-Tito, A., Tito, R., Foster, M. & Spicer, P. (2012). The Human Microbiome Project: lessons from human genomics. Trends in Microbiology, 20(1), 1-4. https://www-clinicalkey-com-au.libraryproxy.griffith.edu.au/service/content/pdf/watermarked/1-s2.0-S0966842X11001934.pdf?locale=en_AU&searchIndex=

Lokugamage, A. & Pathberiya, S. (2019). The microbiome seeding debate – let’s frame it around women-centred care. Reproductive Health, 16(91). 1-9. https://doi.org/10.1186/s12978-019-0747-0

Mueller, N., Dominguez‐Bello, M., Appel, L., & Hourigan, S. (2019). ‘Vaginal seeding’ after a caesarean section provides benefits to newborn children: FOR: Does exposing caesarean‐delivered newborns to the vaginal microbiome affect their chronic disease risk? The critical need for trials of ‘vaginal seeding’ during caesarean section. BJOG: An International Journal of Obstetrics & Gynaecology, 127(2), 301-301. https://doi.org/10.1111/1471-0528.1597

National Human Genome Institute. (2020, September 16). The Human Genome Project. https://www.genome.gov/human-genome-project

Royal Australian and New Zealand College of Obstetrics and Gynaecology. (2016). Vaginal seeding. https://ranzcog.edu.au/news/vaginal-seeding

Wissemann, K. (2018). Exploring Western Australian midwives’perspective on vaginal seeding and how it will affect their practice. Women and Birth, 31(S1), S45-S46. https://www-sciencedirect-com.libraryproxy.griffith.edu.au/science/article/pii/S1871519218305663

Yang, I., Corwin, E., Brennan, P., Jordan, S., Murphy, J., & Dunlop, A. (2016). The infant microbiome. Nursing Research, 65(1), 76-88. https://doi.org/10.1097/nnr.0000000000000133

 

 

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

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

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

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

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

Arguments for the suspension

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

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

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

Benefits of water immersion

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

What the suspension really represents

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

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

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

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

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

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

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

How do we move forward?

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

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

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

In summary

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does intrapartum CTG monitoring save lives?

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

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

 

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

Intrapartum CTG monitoring in low risk populations

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

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

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

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

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

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

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

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

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

Non-experimental research

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

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

Where to next?

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

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

 

Midwives’ mental health during the COVID19 pandemic

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

ANMAC (2009). Midwife accreditation standards 2009. 

ANMAC. (2014). Midwife accreditation standards 2014. 

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

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

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

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

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

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

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

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

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

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

Building birthing on country for the Yuin community

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

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

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

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

 

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

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

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

Transforming maternity care requires the full contribution of the midwifery profession

Adjunct Professor Jocelyn Toohill PhD

Midwives play a critical role in healthcare. Unfortunately, most health leaders, and many health professionals have little understanding of what midwives can do. As a consequence, we have a significantly under-recognised and underutilized midwifery workforce relative to their scope of practice. For communities to have access to the highest standard of maternity care, and for health services to deliver world-class care we must have a midwifery workforce who are supported to work to full scope of practice.

Why is this important?

The “State of the World’s Midwifery” report is the 3rd international report to be published with a global focus to improving availability, accessibility, acceptability, and quality midwifery care. Importantly the report will demonstrate that “Power Comes from the Womb” and will be published by the United Nations Population Fund in 2021. This report will outline the 60-fold benefit that will come from investing in midwifery and highlight the impact midwifery can achieve through adopting a lifetime approach to care. Eighty-seven percent of all essential sexual, reproductive, maternal and newborn healthcare can be provided by midwives. Fifty-six maternal and neonatal outcomes are improved through midwifery practice alone. If we want a first-class health system, we must begin by acknowledging the value of midwives in saving lives and preventing lifetime morbidity, and midwives must be ready to meet this welcome but long overdue recognition.

Acknowledge

To make use of the all the opportunities quality midwifery care might provide for Queensland communities, we need to begin by knowing our existing midwifery workforce. Midwifery is relatively invisible within workforce systems, and is confused within a career structure not designed for the profession . We need to develop and articulate more clearly midwifery position description and generic level statements, that describe what it is that midwives do, when they do it, and where they do it.

Midwives are regulated to provide woman-centred care, and to promote normal physiology for women, both with and without complexities. When a woman has physical, medical, or psycho-social challenges her care does and will include members of the multidisciplinary team and will be guided by the Australian College of Midwives National Consultation and Referral Guidelines. Often health professionals have little understanding of the education preparation or lifesaving skills and knowledge midwives have and this lack of understanding of the scope of a midwife contributes to fragmented care for the woman and disrupts away from providing relationship based care within midwifery continuity. As such the professional role of the midwife must be articulated and embedded in human resource management systems, so that workforce numbers and workforce planning are focused to achieve best practice models where every woman has access to her own midwife. To promote and progress this, midwives must be included in all discussions to have a voice with executive health staff relating to the importance of midwives and of midwifery care.

Innovate

To innovate maternity care, midwifery continuity of carer models need to be scaled up. Despite overwhelming evidence of benefit, few women have access to this model of midwifery care. By tapping into the benefits to women and their families of consistent professional support from midwives during the first 1,000 days of life, we can provide a continuum of connected care and a professional career pathway for midwives that is integrated with child health. We recognise that a consistent and trusted carer means that psychosocial health needs, such as postnatal depression and domestic and family violence, are more likely to be identified earlier and addressed.

Home birth

Queensland is one of only two Australian jurisdictions without publicly funded homebirth. Homebirth is safe and provides improved outcomes in the right population of women. Queensland has strong consumer interest for home birth. During COVID-19 private midwives have reported a 35% increase in homebirths, and higher levels of demand than they can meet. There are concerning reports suggesting that women are giving birth without a midwife or doctor because they cannot afford a private midwife and are fearful of birthing in a hospital. Public health messaging of the safety of birth in hospital has not diminished the numbers of women continuing to seek out this choice. Equity of access to maternity and birth care that is physically and psychologically safe is important. Identifying opportunities for how homebirth could be facilitated remains a significant gap, with ‘hospital in the home’ arrangements perhaps an option.

Birthing on Country

Actioning and embedding culturally appropriate care and acknowledging the importance of birthing on country to Aboriginal and Torres Strait Island women is paramount in providing a world class health system and achieving sustainable development goals. Scaling up midwifery continuity of care with Aboriginal and Torres Strait Island women is vital. A major contributor to poor outcomes for Aboriginal and Torres Strait Island women is preterm birth, and we know that this is reduced by 50% where mothers receive midwifery continuity of care. Through implementing recommendations of the Queensland Rural Taskforce Report, maternity care can be provided closer to home and build continuity models. Technology will be a major conduit for midwives to connect women living rurally with specialist services.

Transform

Transforming maternity care will only come from the realisation of the full capacity of the midwifery profession. Currently, there are few midwives who have graduated in the past 12 years from a Bachelor of Midwifery program holding leadership roles. In 2018 surveys showed that contemporary midwifery education and practice remain poorly understood, with significant numbers of midwives indicating they were restricted from working to their full scope of practice. For those in leadership roles, a clear understanding of the differences between nursing and midwifery is necessary to grow and show the benefits of the midwifery workforce. Upon graduation midwives should be articulated directly to continuity models rather than restricted to and deskilled in historical and fragmented graduate programs. Ensuring culturally appropriate support is in place to attract and retain Aboriginal and Torres Strait Islander midwives is also key to building an equitable and inclusive workforce.

Additionally, through ensuring all women have access to a midwife – and specifically within a relationship-based continuity model where they are working to full scope – will assist in addressing the one in three women who have trauma symptoms from a poor birth experience or from feelings of having been treated disrespectfully. The protective factor for women is having a known midwife who understands her needs. Trust builds over time through cumulative education, information sharing, and decision-making, where the woman can feel confident in her midwife’s advocacy of her needs. Through this support – and regardless of birth or maternity outcome – the woman’s feelings of safety and control are likely to result in improved perinatal mental health, adaption to early parenting and greater capacity to meet the developmental needs of her child. Women who receive midwifery care are more likely to feel empowered, experience shared decision making and be more satisfied with their care.

Summary

For ongoing improvements in maternity care to be achieved we need to make the best use of our existing workforce by expanding opportunities for midwives to provide continuity of care. We need to be ready for the recommendations coming from the State of the World’s Midwifery report.

All midwives – regardless of the model they choose to work – in are vital to promoting the profession and to achieving a world class maternity system. Midwives are potent, and we must ensure that how midwives are educated and regulated to work is supported, translated to practice, and for women to have increased access. It has been said previously, that if midwifery were a pill, everyone would be prescribed it. I commend all midwives to primarily advocate for women, but fundamentally understand that universal access to best practice midwifery continuity is dependent on us all.

While our profession is predominantly women, all midwives, regardless of gender must safeguard gender equality. We must call out poor care or inequity. To be effective we must continue to strengthen our profession and stand united so women know, our communities know, and our governments know who we are, what we do and why midwifery is so fundamentality important to women, to strong communities and to generational health. Without this commitment the usefulness of the 2021 State of the World’s Midwifery report to our profession may be lost.

New research from the Transforming Maternity Care Collaborative Team

Collectively, the Transforming Maternity Care Collaborative generate a large volume of high quality, impactful research. This week has seen the publication of five new papers from our team members in the Women and Birth journal. You can access the full text of each of these via the links below. Settle in with a cuppa and enjoy getting up to date.

Intrapartum CTG monitoring does not improve perinatal outcomes.

Authors: Dr Kirsten Small, Associate Professor Mary Sidebotham, Professor Jennifer Fenwick, Professor Jenny Gamble.

This systematic literature review identified all randomised controlled trials and non-experimental evidence which has examined whether the use of CTG monitoring during labour rather than intermittent auscultation reduces perinatal mortality or cerebral palsy rates in babies born to women considered to be at high risk. No improvement in mortality was found, while an increase in the cerebral palsy rate was noted when CTG monitoring was used during preterm labour.

“High-quality research is urgently required to identify which women, if any, obtain a perinatal benefit from intrapartum CTG monitoring.”

Access this paper here.

Measuring midwifery students’ experiences of learning in clinical practice environments.

Authors: Ms Marnie Griffiths, Professor Jennifer Fenwick, Professor Jenny Gamble, Professor Debra Creedy.

Learning in a clinical environment is a key component of a comprehensive midwifery education program. Being able to measure how well specific learning environments support midwifery students as they develop the knowledge and skills required for professional practice is important. This paper reports on the development and testing of the MidSTEP tool which offers a robust way to capture students’ perceptions of the clinical practice component of their degree. Students indicated high level support for the statements that the clinical environment supported their learning, enabled them to work across the full scope of practice, and fostered a self-directed approach to learning.

Access this paper here.

Placing students in the driver’s seat.

Authors: Ms Valerie Hamilton, Professor Kathleen Baird, Professor Jennifer Fenwick

This research reports on students’ experiences of learning to provide midwifery care in a student-led midwifery clinic providing antenatal and postnatal care. Students who were on-call for individual women were supported to provide antenatal and postnatal care under the supervision and guidance of their university practice lecturer. “Being in the driver’s seat” was the major theme of the findings, with students reporting a sense of being in control and feeling like “a real midwife”. Students described growing in confidence over time and feeling competent to step into practice.

Access this paper here.

Stepping from student to employment through simulated employment interviews.