Is the organisation and structure of hospital postnatal care a barrier to quality care? Findings from a state-wide review in Victoria, Australia

OBJECTIVE: to describe the structure and organisation of hospital postnatal care in Victoria, Australia. DESIGN: postal survey sent to all public hospitals in Victoria (n=71) and key-informant interviews with midwives and medical practitioners (n=38). SETTING: Victoria, Australia. PARTICIPANTS: providers of postnatal care in Victorian public hospitals. FINDINGS: there is significant diversity across Victoria in the way postnatal units are structured and organised and in the way care is provided. There are differences in numerous practices, including maternal and neonatal observations and the length of time women spend in hospital after giving birth. Although the benefits of continuity of care are recognised by health care providers, continuity is difficult to provide in the postnatal period. Postnatal care is provided in busy, sometimes chaotic environments, with many barriers to providing effective care and few opportunities for women to rest and recover after childbirth. The findings in this study can, in part, be explained by the lack of evidence that has been available to guide early postnatal care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: current structures such as standard postnatal documentation (clinical pathways) and fixed length of stay, may inhibit rather than support individualised care for women after childbirth. There is a need to move towards greater flexibility in providing of early postnatal care, including alternative models of service delivery; choice and flexibility in the length of stay after birth; a focus on the individual with far less emphasis on care being structured around organisational requirements; and building an evidence base to guide care.     

In a tertiary maternity hospital,when should a paediatrician be present in the delivery room?

Objective: 10% of newborns require positive pressure ventilation (PPV) at birth. There are few data on prenatal or early postnatal factors that are predictive of the need for a paediatrician in the delivery room. The study analysed prenatal obstetric and early postnatal factors associated with the requirement for paediatrician assistance in this setting.

Methods: Over a three-month period, all consecutive births in a tertiary hospital’s maternity unit were prospectively evaluated with regard to the need for paediatrician assistance (requested either before or after the delivery), the requirement for resuscitation, and transfer to a neonatal intensive care unit (NICU).

Results: For a total of 584 consecutive births, paediatrician assistance was requested before delivery in 170 cases (30.5%) and after in 78 cases (13.3%). 78% of the newborns requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring transfer to the NICU matched recently published prenatal criteria for paediatrician assistance. Along with a low Apgar score and a cord blood pH?<7.20, these criteria covered 95% of the prenatal and early postnatal requests for paediatrician assistance.

Conclusions: These criteria for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for paediatrician assistance.     

High rate of unintended pregnancy among pregnant women in a maternity hospital in Córdoba, Argentina: a pilot study

Background  

Although Argentina has a new law on Reproductive Health, many barriers continue to exist regarding provision of contraceptive methods at public healthcare facilities.     

Migration status and perinatal parameters in a Greek public maternity hospital: an illustration of the “healthy immigrant effect”

Background: Although socioeconomic disparities adversely affect health, studies referring to the “healthy immigrant effect” imply more favorable health outcomes in immigrants than natives. We aimed to investigate the impact of immigration on several perinatal parameters.

Methods: Birth records (01/01/2010???31/12/2014) from a public maternity hospital in Athens, Greece were reviewed for maternal (ethnicity, age, delivery mode) and neonatal (gender, birthweight, gestational age) variables. Immigrants were classified by country of origin, according to Human Development Index. Comparison of results between Greeks and immigrants were made. Stratification by maternal age (< and ≥35 years) was conducted to test for confounding and interaction.

Results: Almost one-third of 7506 deliveries applied to immigrants; 36.3% of Greeks and 19.2% of immigrants [risk ratio (RR)?=?0.53, 95% confidence interval (CI)?=?0.52–0.54] delivered at ≥35 years; 10.5% of Greek and 7.0% of immigrant neonates weighted <2500?g (RR?=?0.67, 95% CI?=?0.61–0.74); 10.9% of Greeks and 8.1% of immigrants were born <37 wks (RR?=?0.74, 95% CI?=?0.67–0.82); 55.7% of Greeks and 48.2% of immigrants delivered by caesarean section (RR?=?0.87, 95% CI?=?0.85–0.88).

Conclusion: We found that immigrant women deliver at a younger age, vaginally, more mature, and heavier neonates. Furthermore, we confirmed that the protective effect of immigrant status could not be explained by maternal age only.     

Unconscious collusion: An interpretative phenomenological analysis of the maternity care experiences of women with obesity (BMI≥30 kg/m²)

Backgroundobstetric and midwifery literature continually emphasise incidence and consequence of obesity in pregnancy. However, they offer less consensus on how best to support women who are obese. Therefore, this study explores in depth the lived experience of women who have a Body Mass Index (BMI) ≥30 kg/m². This exploration provides a bio-psycho-social understanding of the lived experience of women to identify how best to support them throughout their childbirth experience.Methodsan Interpretative Phenomenological Analysis (IPA) design was adopted for this qualitative study. Purposive sampling of participants was conducted on the postnatal wards of a maternity hospital in the Republic of Ireland. In total, 15 participants volunteered to take part in semi-structured interviews conducted at six to ten weeks postnatally. Data were analysed utilising the IPA framework.Findingsthe results indicate that participants were conscious of the problematics of communicating obesity in pregnancy. The narrative data revealed an unconscious collusion between healthcare professionals and women as they navigate obesity related conversations. The behaviours related to unconscious collusion are incorporated in the sub-ordinate themes; ‘just recorded and that's all’, ‘but what's eating healthy? ‘pussy footing around’ and ‘I hate that word obesity.Conclusions and implications for practicethe findings highlight a lack of information received by participants from healthcare professionals regarding increased BMI or weight management. The data suggests that healthcare professionals appeared to collude with women to avoid challenging discussions regarding obesity. This may be related to avoidance on participants’ part and/or may be linked with healthcare professionals’ reluctance to communicate issues relating to increased BMI. Although participants were generally unhappy with the communication skills of health professionals, they readily acknowledged the sensitive nature of obesity related communications. The findings provide healthcare professionals with an important insight into issues of effective communication and obesity related healthcare promotion from the woman's perspective in order to enhance provision of appropriate health information and maternity care to women who have an increased BMI.     

Lack of antenatal care,education, and high maternal mortality in Kassala hospital,eastern Sudan during 2005–2009

The aim of this study was to investigate the incidence and causes of maternal deaths at Kassala maternity hospital, eastern Sudan during 2005–2009. All maternal deaths during this period were reviewed and classified retrospectively. The medical file of consequent women who were discharged from the same ward in the hospital was reviewed to act as control for the maternal death. There were 132 maternal deaths and 20,485 (644/100,000) live births. Septicemia, preeclampsia/eclampsia, hemorrhage, anemia, viral hepatitis, and malaria were the causes for maternal mortality. Primipare (OR?=?3.3, CI?=?1.6–6.9, p?=?0.001), lack of antenatal care (OR?=?3.9, CI?=?1.6–9.5, p?=?0.002), illiteracy (OR?=?2.6, CI?=?1.4–4.8, p?=?0.002), and rural residence (OR?=?2.2, CI?=?1.2–4.1; p?=?0.008) were the predictors for maternal death. The levels of maternal education and antenatal attendance should be raised to reduce the high maternal mortality.     

‘No more strangers’: Investigating the experiences of women,midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia

Objectiveto describe the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling Aboriginal women transferred to a regional centre in northern Australia for maternity care and birth.Designa mixed method design within a Participatory Action Research approach was used. Qualitative findings are presented here. Data for this paper were collected from semi-structured interviews, field notes and observations and analysed thematically.Settingthe ‘top end’ of the Northern Territory of Australia.Participantsa total of 66 participants included six MGP midwives, two Aboriginal Health Workers and one Senior Aboriginal Woman working in the new model; eight hospital midwives; 34 Department of Health staff, three staff from other agencies; and 12 remote dwelling Aboriginal women who used the service.Findingsthe study generated one overarching theme, it's not a perfect system but it's changing. This encompassed improvements to the services evident to all participants. Core themes related to the previous maternity service which was described as the arduous journey, the new model was seen as a new way of working and a resultant very different journey occurred for Aboriginal women using the service.Key conclusions and implications for practicethere was a dissonance between the previous culture of maternity services and the woman centred focus of the new model. Over 12 months initial resistance to the new model diminished and it became highly valued. The transfer of information between the regional service and remote community health centres improved as did the safety and quality of care. Aboriginal women can access continuity of carer in the regional centre for the first time and reported a more positive experience with maternity services. The new model appears to have changed the cultural responsiveness of the regional maternity service; and care provided for remote dwelling women within this service. The qualitative findings inform others seeking to implement a similar model of care for remote dwelling women transferred to a regional centre for birth.     

How is maternal psychosocial health assessed and promoted in the early postnatal period? Findings from a review of hospital postnatal care in Victoria, Australia

OBJECTIVE: to describe how women's maternal health, particularly at a psychosocial level, is assessed and promoted during the postnatal hospital stay. DESIGN: postal survey of public hospitals providing postnatal care and interviews with care providers. SETTING: all publicly funded maternity units and selected health professionals in Victoria, Australia. PARTICIPANTS: hospital postal survey: sixty six hospital respondents; interviews: 38 maternity unit managers, clinical midwives and medical practitioners. FINDINGS: there was little consistency across the State in relation to routine observations of the mother. Physical checks were much more common than enquiring about how women felt physically. Practice in psychosocial assessment was also diverse, with care plans/maps (clinical pathways) being the main tool to guide assessment. Most participants reported that psychosocial assessment was undertaken during pregnancy. Follow-up after birth also varied. Hospital respondents reported that emotional well-being is assessed postnatally by observation and conversation with women. Participants who were interviewed reported that midwives had mixed skills in assessing and dealing with complex psychosocial issues. Three hospitals administer the Edinburgh Postnatal Depression Scale to women in the days after birth, and three hospitals provide routine sessions of structured debriefing. Survey participants reported that the busy and, at times, chaotic nature of postnatal wards affected the provision of care and the level of psychosocial support offered to women. KEY CONCLUSIONS: although one of the stated aims of early postnatal care is the promotion of maternal well-being, the diversity of practices and the routine nature of many of these practices suggest that care is often not individualised or woman-centred. The reliance of detecting and managing women with particular psychosocial issues during pregnancy results in this aspect of care being given less priority postnatally than may be ideal. IMPLICATIONS FOR PRACTICE: strategies are required to provide health professionals with guidelines and skills to enhance the detection of women who have, or have the potential to develop, health problems after birth. This requires a reorganisation of the way early postnatal care is provided in relation to the use of routine practices; the ability of caregivers to spend time with women in an environment that offers privacy and confidentiality; the structuring of care around individual needs; and opportunities for women to be cared for by caregiver/s with whom they have met before.     

Does a policy of earlier induction affect labour outcomes in women induced for postmaturity? A retrospective analysis in a tertiary hospital in the North of England

Objectivesto investigate whether a change in the management of postmature pregnancy to earlier induction affects the length of labour and the induction process. Secondly, to assess the feasibility of the research process to inform a future larger study.Designa change in management of postmature pregnancy in an NHS hospital in October 2013, from induction at 42 weeks gestation to induction between 41–42 weeks, provided an opportunity to conduct a retrospective analysis. Pre-existing data from the maternity database and casenotes were collected and primary outcomes analysed using the Mann-Whitney test and the Hodges-Lehman confidence interval for differences in medians.Settinga large city based tertiary referral hospital in the North of England.Participants125 women induced before the change in policy were compared with 309 women induced after the change.Measurementsprimary outcomes were length of 1st and 2nd stage of labour, overall length of labour, length of induction to established labour and length of induction to birth.Findingsthe median overall length of labour for women induced at 42 weeks was 6.5 hours, while for women induced at 41–42 weeks this was 5.2 hours. The difference was not statistically significant (p=0.15, 95% CI for median difference −0.27 to 1.93 hours) with a small effect size (Pearson's r=−0.08). The median length of induction to birth was 13.6 hours for women induced at 42 weeks and 16.5 hours for women induced at 41–42 weeks. This difference was also not statistically significant (p=0.14, 95% CI for median difference −7.25 to 1.20 hours) with a small effect size (Pearson's r=−0.13).Key conclusions and implications for practiceThis study demonstrated no statistically significant differences in length of labour and induction following a change in the management of postmature pregnancy to earlier induction. A large study is needed to establish definitively the effects of earlier induction on labour outcomes.     

Clinical characteristics and pregnancy outcomes of Syrian refugees: a case–control study in a tertiary care hospital in Istanbul,Turkey

Purpose

We aimed to compare the clinical characteristics and pregnancy outcomes in women who are Syrian refugees and Turkish women who are non-refugees at a maternity center in Istanbul, Turkey.

Methods

A total of 600 singleton pregnancies who delivered at Sisli Hamidiye Etfal Training and Research Hospital were included in the study. Demographic data, obstetrical history, clinical findings, obstetrical and neonatal outcomes were compared between 300 Syrian refugees and 300 control patients.

Results

The Syrian refugee patients were significantly younger than Turkish patients. The percentage of adolescents aged 12–19 years were significantly higher in the Syrian patients (14.3 vs. 5.3 %, p < 0,001). 41.3 % of the refugee patients had no antenatal care. However, this ratio was only 7.7 % for the control group (p < 0.001). Preterm birth rates showed no difference between the groups, however, postterm birth rates were significantly higher in the control group. Low Birthweight (<2500 gr), oligohydramnios, stillbirth and fetal anomaly rates were not different between the two groups.

Conclusions

In comparison to non-refugee control patients, refugee women in our study had poor antenatal care but no adverse perinatal outcomes were observed. Further larger multicenter studies may provide more convincing data about obstetric outcomes in the Syrian refugee population as well as adolescent pregnancies in this population.

     

Audit of perinatal deaths in a tertiary level hospital in Latvia (1995–1999) using the Nordic-Baltic perinatal death classification: Evidence of suboptimal care

Objective.?The objective of this study was to explore applicability of the Nordic-Baltic perinatal death (PND) classification in a single hospital via evaluation of changes of the preventability of PND over the time period in a tertiary level perinatal care center in Latvia.

Method.?All PND cases during the period 1995–1999 at a tertiary referral perinatal care center, the Riga Maternity Hospital (RMH), were analyzed using the common Nordic-Baltic PND classification.

Results.?The total perinatal mortality rate (PNMR) did not decline at the RMH over the study period. The rate of antenatal and intrapartum deaths at <28 weeks of gestation increased (p < 0.01). Early neonatal deaths at 28–33 weeks of gestation with a low 5-minute Apgar score became less frequent (p < 0.05). There was a trend towards more cases of probably suboptimal care (p < 0.005) and the proportion of preventable PND cases increased from 14.7% in 1995 to 36.4% in 1999 (p = 0.01).

Conclusion.?The perinatal audit performed at the RMH using the Nordic-Baltic PND classification disclosed a requirement for further improvement of perinatal care in the hospital. The classification can be used to evaluate the preventability of perinatal death cases in a single hospital, and its application in other hospitals in Latvia could provide information necessary for the improvement of perinatal care in the country.     

The analysis of twin pregnancy and labour in the Department of Obstetrics, Medical Academy, Gdańsk

OBJECTIVES: According to the literature the frequency of twins is increasing due to technics af assisted reproduction. Many complications of pregnancy and delivery are more likely to develop during multiple pregnancy. DESIGN: Aim of the study was to analyze labour and delivery in multiple pregnancy and assess the neonate's condition. MATERIALS AND METHODS: Authors analyzed labour and delivery and neonate's condition in twin pregnancies in Medical University of Gdansk, Poland in 1991-1995 with birth weight at least 1000g. We assessed women's age, fetuses presentation, week of pregnancy at the delivery, mode of delivery, Apgar score, weight and crown-rump length after birth and early neonatal period. RESULTS: Mean age of pregnant women was 30.0 years (18-43). Mean birth weight for the first fetus was 2412 + 601 g and for the second one--2485 + 630 g. Mean SI for the first fetus was 49.8 + 4.4cm, for the second one--50.0 + 4.15 cm. Apgar core was analyzed separately for the first and the second twin according to the presentation and mode of delivery--we found better condition of the second babies delivered from transverse presentation by the cesarean section comparing to those born vaginally. 73% of the pregnancies with the first fetus in the cephalic presentation were delivered vaginally, in other situations--cesarean section was preferred. CONCLUSIONS: At the transverse presentation of the second twin elective cesarean section seems better for the second twin.     

Evaluation of sperm’s chromatin quality with acridine orange test, chromomycin A3 and aniline blue staining in couples with unexplained recurrent abortion

Objective

To evaluate the sperm’s chromatin quality in couples with spontaneous recurrent abortion.

Methods

Thirty couples with spontaneous recurrent abortion (case group) and 30 fertile couples (control group) referring to Zeinabieh Gynecology clinic of Shiraz were included. Semen samples were collected for each participant and were used for standard semen analysis and sperm nuclear maturity tests including Chromomycin A3 (CMA3), Aniline Blue (AB) staining and Acridine Orange (AO) test (by light microscopy).

Result

Patients in case group had significantly higher percentage of CMA3 (p?<?0.001) and AB (p?<?0.001) positive spermatozoa compared to controls. However AO results did not differ significantly between groups (p?=?0.656). Sperm morphology and progressive motility were negatively correlated with CMA3 (p?=?0.001 and p?=?0.043) and AB (p?=?0.015 and p?=?0.031) respectively.

Conclusion

Evaluation of the sperm’s quality via CMA3 and AB staining could be considered as one of the complementary tests of semen analysis for assessment of male factor in couples with spontaneous recurrent abortion.     

Poor quality of antenatal care services—Is lack of competence and support the reason? An observational and interview study in rural areas of Lao PDR

Objective

to explore the health-care providers' performance and their own perceptions of the ANC services they provide.

Design, setting and participants

this cross-sectional exploratory survey was carried out in 2009 at four district hospitals and 18 health centres in Khammouane and Champasack provinces in rural areas of Laos.

Measurements and findings

combinations of quantitative and qualitative methods were used: (i) 59 observations of ANC sessions (components performed and equipment used); (ii) 26 semi-structured interviews with health-care providers engaged in ANC services, interpreted through content analysis. The findings indicated an overall poor quality and performance of ANC services in rural health facilities with lack of routines, scarce or insufficient equipment and limited skills among providers. The health-care providers gave an often pessimistic picture of their competence and motivation to work with ANC. Some articulated a resignation due to lack of feedback from the patients and they expressed a need for support from health-care superiors. Compared to the district hospitals, the health centres were less well-equipped and supplied, and the providers had a heavier workload, because all activities including ANC were carried out by the same provider. The average consultation time for each woman was 5 mins.

Conclusions

the quality of ANC services in rural health facilities in Laos was poor due to lack of resources, the providers' limited skills concurrent with inadequate routines and insufficient backup from superiors.

Implications for practice

to comply with national and international recommendations for ANC services, our suggestion is to improve the quality of the rural health facilities in Laos by providing basic equipment, support from experienced superiors and in-service training.