Weight management during pregnancy: A systematic review of qualitative evidence

Backgroundincreasing overweight and obesity rates in pregnant women present health risks to mother and unborn infant.Objectivesto identify barriers and facilitators to implementing and carrying out maternal weight management interventions.Search strategysearches were carried out in medical, midwifery and nursing databases, augmented by hand searching of midwifery journals.Selection criteriaarticles were included that were published in the UK after 1990, with a focus on women's and health professional's views about weight management during pregnancy.Data collection and analysisfrom 6423 citations, 126 full text papers were retrieved. Of these, 18 (reporting 17 studies) fulfilled the inclusion criteria. Included papers were assessed for quality. Reported findings were analysed and synthesised using thematic analysis.Main resultsa major theme was access to relevant and appropriate information; advice was reported as vague or inadequate. Overweight or obese women reported feelings of stigmatisation during routine examinations. Health professionals reported a reluctance to discuss weight with larger women. Perceived risk to the fetus as well as changes in women's physiological responses to pregnancy, were reported barriers to optimal physical activity and dietary intake. Perceptions of control were related to women's feelings about their body image.Conclusionevidence suggests that the complexity of interactions with advice sources, bodily changes, feelings of control, as well as perceived risks may explain the relative ineffectiveness of weight management interventions during pregnancy. Focusing on healthy diet and physical activity levels may be more useful and less stigmatising than focusing on weight.     

Midwifery and the LGBT midwife

Objective

to identify, through searching the published literature, midwifery's attitudes to gay and lesbian midwives.

Design

a selective literature review.

Findings

UK-based material was sparse. Items on midwifery and nursing and medicine and on midwifery in non-UK countries were accessed. Issues emerging include the salience of ‘coming out’, of education, of culture, of forming relationships with childbearing women and the difficulty of authoritative research.

Key conclusions

the midwifery literature on LGBT colleagues corresponds with that identified in nursing almost three decades ago. The lack of recognition of LGBT midwives carries personal and organisational implications.

Implications for practice

discriminatory attitudes may be difficult to resolve by education. Research on LGBT colleagues is fraught with difficulties. Various aspects of culture affect the acceptance of the colleague who is gay or lesbian. It is uncertain whether the midwife–woman relationship is less easily achieved by the gay or lesbian midwife.     

Childbirth and the illness focus

Childbirth is essentially women's business, a natural female act being performed since the beginning of mankind. However, as Western society has evolved, so too has the management of childbirth. It is the medical profession that has gained control of providing care for childbearing women, to the detriment of many women's experiences. The societal expectations on childbearing women, the iatrogenic effects of pregnancy being treated as an illness under the medical model, and the implications for the profession of midwifery will be discussed.     

Midwifery scope of practice among staff nurses: A grounded theory study in Gujarat,India

Backgroundmidwifery is a part of the nursing profession in India. This current study explores and describes the midwifery scope of practice among staff nurses.Methodsa grounded theory approach was used to develop a model. Twenty-eight service providers from the maternity sections of public health facilities, selected through purposive and theoretical sampling were interviewed in-depth. Unstructured observations in the labour wards were also used for developing the model.Findingsthe midwifery practice of staff nurses was limited in scope compared to international standards of midwifery. Their practice was circumstance driven, ranging from extended to marginal depending on the context. Their right to practice was not legally defined, but they were not specifically prohibited from practice. As a consequence, the staff nurses faced loss of skills, and deskilling when their practice was restricted. Their practice was perceived as risky, when the scope of practice was extended because it was not rightfully endorsed, the nurses having no officially recognized right to practice midwifery at that level. The clinical midwifery education of nursing and midwifery students was marginalized because the education of medical students was given priority, and the students only got exposed to the restricted practice of staff nurses.Conclusionsunclear definitions of the right to practice and the scope of practice have led to the un-utilized potential of staff nurses practising midwifery. This is detrimental because India faces an acute shortage of qualified personnel to meet the need in providing human resources for maternal health.     

Women's lived experience of compassionate midwifery: Human and professional

ObjectiveTo develop an understanding of women's lived experience of compassionate midwiferyDesignA qualitative study using the principles of Interpretive Phenomenological Analysis (IPA). Data was collected during interviews with 17 women who identified themselves as having received compassionate midwifery care.FindingsWomen participants' experience of compassionate care from midwives was experienced through a sense of a midwife Being With them, Being in Relationship with them and Empowerment. Women were also aware of the way midwives were able to Balance potentially conflicting aspects of their work, in order to provide compassionate care.Two other themes which emerged through extensive analysis of the data related to how women set their experience of compassion in the context of their personal suffering and that compassion made a difference. These themes will be reported separately.Conclusion and implications for practiceThe unique contribution of this study was to provide a window into the nature of women's lived experiences of compassionate midwifery and thus building, understanding around the qualities of compassionate midwifery and its impact on women. The findings are important because they challenge assumptions that compassion is ill-defined and therefore difficult to teach. On the contrary, compassionate midwifery was easily identified by women participants and had the features of an effective intervention for relieving their suffering. A dynamic model of Compassionate Midwifery in Balance has been proposed, providing a much-needed tool to inform practice, education and policy. Further research will build on this work by focussing on women in varied circumstances, environments and cultures and on understanding the lived experience of compassionate midwifery from the midwife's perspective.     

A theory of the aims and objectives of midwifery practice: A theory synthesis

IntroductionEvery discipline has a dichotomous objective by which it recognizes whether its work has been successful (Vogd, 2011). For midwifery care, no objective has been set in this way so far. This also has implications for measuring quality, because quality of care is only measurable if objectives have been identified. This paper aims to contribute to theory formation in midwifery science by analysing existing concepts and theories and preferences of women to midwifery care to answer the question of the dichotomous objective of midwifery.Method and findingsThe method of theory synthesis (Walker and Avant, 2011) was used to analyse existing theories and concepts of midwifery care and literature-based preferences of women to midwifery care and synthesize them with regard to the objectives of midwifery care. The synthesis took place in the form of a means-end chain to extract the dichotomous target of midwifery care. In this way, the objectives of midwifery could be compared and linked from both the scientific and from women's perspective. The resulting means-end chain model of the process of midwifery describes the aims and objectives of midwifery from the point of view of women on three levels.DiscussionThe hierarchical model of the process of midwifery presented here is a first attempt to illustrate the aims and objectives of midwifery practice in a means-end chain model in order to facilitate discussion on the topic and to make the quality of midwifery care measurable. Measurement is a first step towards improving quality of midwifery care and thereby improving women's reproductive capabilities.     

Iranian primigravid women's awareness of the risks associated with delayed childbearing

Abstract

Objectives To explore older (35 years +) primigravid women's knowledge of the risks of delayed childbearing and to identify the characteristics of those with limited knowledge.

Methods A cross-sectional survey involving 675 primigravid women in Tehran, Iran, using a cluster random sampling method at the first prenatal visit. A validated questionnaire assessed the women's awareness of delayed-childbearing risks.

Results Women variously identified conception difficulties, gestational diabetes, hypertension, multiple birth, caesarean section, preterm delivery, stillbirth, Down's syndrome, congenital abnormality, and low birth weight, as associated with delayed childbearing. Awareness of infant risks ranged between 10 and 72%. Awareness of maternal risks were independently related to the women’s educational levels (odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.12–3.38), planned pregnancy (OR: 1.87; 95% CI: 1.25–2.78) and maternal age ≥ 40 (OR: 1.24; 95% CI: 1.14–2.53). Women aware of infant risks were significantly likely to be aged ≥ 40 (OR: 1.87; 95% CI: 0.01–5.12), have post-graduate education (OR: 2; 95% CI: 1.90–4.42), and have a planned pregnancy (OR: 1.99; 95% CI: 1.03–5.12).

Conclusion Women are largely unaware of the potential complications of delayed childbirth. Understanding the risks is important for reproductive healthcare providers and policy makers in providing appropriate information to enable women to make informed decisions on the timing of conception.     

The experiences of women,midwives and obstetricians when women decline recommended maternity care: A feminist thematic analysis

Backgroundpregnant women, like all competent adults, have the right to refuse medical treatment, although concerns about maternal and fetal safety can make doing so problematic. Empirical research about refusal of recommended maternity care has mostly described the attitudes of clinicians, with women's perspectives notably absent.Designfeminist thematic analysis of in-depth, semi-structured interviews with women's (n=9), midwives’ (n=12) and obstetricians’ (n=9) about their experiences of refusal of recommended maternity care.Findingsthree major interrelated themes were identified. “Valuing the woman's journey”, encapsulated care experiences that women valued and clinicians espoused, while “The clinician's line in the sand” reflected the bounded nature of support for maternal autonomy. When women's birth intentions were perceived by clinicians to transgress their line in the sand, a range of strategies were reportedly used to convince the woman to accept recommended care. These strategies formed a pattern of “Escalating intrusion”.Key conclusions and implications for practicedeclining recommended care situated women at the intersection of two powerful normative discourses: medical dominance and the patriarchal institution of motherhood. Significant pressures on women's autonomy resulted from an apparent gap between clinicians’ espoused and reported practices. Implications for policy and practice include a need for specific guidance for clinicians providing care in situations of maternal refusal, the potential value of an independent third-party for advice and advocacy, and the development of models that support reflexive practice amongst clinicians.     

Prenatal Detection of Down's Syndrome

Advances in understanding the causes and prenatal diagnosis of Down s syndrome are explained. The population of women of childbearing age to whom these advances are most important is delineated, and counseling and nursing implications are discussed. A review of the genetic causes of Down's syndrome is also presented.     

Immersive simulation training: Comparing the impact on midwifery and paramedic students’ confidence to perform basic life support skills

BackgroundSimulated practice using high fidelity has been shown to have significant benefits in the medical and nursing field. However, the benefits amongst paramedical and midwifery students are not well known.AimThe aim of this study was to explore and compare the impact of Immersive Simulation Training (IST) on midwifery and paramedic students' confidence to perform a skill (basic life support) in real-life stressful and life-threatening scenarios.DesignA mixed-method approach with an explanatory sequential design was used.Setting and participantsSeventeen first year student midwives and paramedics were recruited from one Higher Education Institution.MeasurementsA validated confidence questionnaire and focus groups were used to collect data.FindingsStudents' confidence following IST was significantly improved when compared to confidence following conventional simulation training (CST); a statistically significant increase of 6.71 (95% CI, 3.57 to 9.84), p < 0.001. Additionally, five themes were identified; 'Needing a solid foundation', 'The role of peer support' and 'It is just not real' following CST and 'A steep learning curve' and 'A whole new world' following IST.ConclusionThe study identified the important role of CST to establish a foundation but the need for escalation to IST to ensure deeper learning and preparedness for real life scenarios and should both be integrated in curricula.     

Gestational Age Standardized Nuchal Thickness Values for Estimating Mid-Trimester Down's Syndrome Risk

Objective: Our aim was to develop gestational age standardized indices of fetal nuchal thickening. In addition, we wanted to develop a method for combining nuchal thickness data with maternal age for calculating individual Down's syndrome risk.

Methods: Nuchal thickness was measured prospectively in pregnancies undergoing genetic amniocentesis. A regression equation for expected median nuchal thickness based on the biparietal diameter (BPD) was developed. Nuchal thickness values were expressed as multiples of the median (MoM). Additionally, a new parameter, percentage increase in nuchal thickness (PIN) (measured minus expected nuchal thickness) ×100/expected nuchal thickness, was used. Receiver operator characteristics curves for Down's syndrome detection based on nuchal thickness values expressed as MoM, PIN, and in mm were compared. Logxo transformation of MoM data resulted in a Gaussian distribution, and the Down's syndrome likelihood ratios were calculated based on the heights of the Gaussian curves. Likelihood ratios were also calculated based on PIN values. The screening efficiency of maternal age alone was compared to age plus MoM, and age plus PIN values by multiplying age-related risk by the likelihood ratio corresponding to the given nuchal thickness MoM or PIN values.

Results: There were 3,574 chromosomally normal and 50 Down's syndrome fetuses in the study. Both PIN and MoM values for nuchal thickness were closely correlated (R = 1.00, P < 0.001) and each was poorly correlated with gestational age (R = 0.018, P = 0.28). The Down's syndrome screening efficiency of PIN, MoM, and nuchal thickness values in mm were not significantly different. The addition of nuchal thickness data to maternal age-related risk significantly improved the Down's syndrome screening efficiency: Area under the ROC curve for maternal age risk = 0.58, maternal age + PIN area = 0.79 (P < 0.001 compared to maternal age alone) and for maternal age + MoM = 0.77 (P < 0.005 compared to maternal age alone).

Conclusions: The development of gestational age standardized nuchal thickness indices makes it possible to combine ultrasound and maternal age-related risk to derive individual Down's syndrome odds.     

Childbearing motivational patterns of primiparous women of advanced age and their partners

Objective: This study aimed to: (1) describe the positive and negative childbearing motivations of primiparous women of advanced maternal age and their partners (AMA group) compared with their younger counterparts (comparison group) during pregnancy; (2) identify distinct childbearing motivational patterns in the AMA group; and (3) to explore their correlates. Background: First childbirth at advanced maternal age is a growing social concern, but few studies have explored couples’ childbearing motivational patterns, challenging the stereotypes that presuppose that this reproductive trend reflects ambivalent motivations. Methods: Forty-six couples in the AMA group and 44 couples in the comparison group responded to the Childbearing Motivations Scale during the third trimester of pregnancy. Results: The AMA group differed from the comparison group in positive but not negative childbearing motivations. Two childbearing motivational patterns were identified in the AMA group. The ‘realistic childbearing motivational pattern’ was characterised by highly positive motivations that coexisted with moderate negative motivations. The ‘disengaged childbearing motivational pattern’ was characterised by moderate positive motivations that coexisted with low negative motivations. These two patterns had comparable frequencies for women and men. Women who were less satisfied with their professional life and experienced prior adverse pregnancy outcomes and men who reported a higher deviation from child-timing expectations were more likely to report a ‘realistic childbearing motivational pattern’. Conclusion: Healthcare providers should avoid stereotyped views and develop couple-focused interventions across the reproductive lifespan and during antenatal care to promote satisfactory decisions and to prepare couples for the positive aspects and demands of childrearing.     

“It's Part of Me,Not All of Me”: Young Women's Experiences of Receiving a Diagnosis Related to Diverse Sex Development

Study ObjectiveTo understand young women's experiences of receiving a diagnosis related to diverse sex development.DesignA qualitative narrative analysis of interviews.SettingKarolinska University Hospital.ParticipantsNine women (aged 20-26 years) with complete androgen insensitivity syndrome, XY or XX gonadal dysgenesis.InterventionsSemistructured interviews.Main Outcome MeasuresA narrative approach was used to analyze the interviews. This involved identification of individual narratives of receiving the diagnosis, as well as identification of key issues that were common across interviews.ResultsThe analysis showed how participants' prediagnosis life experiences framed how medical information was perceived upon diagnosis. All participants had been informed about their condition before the study, but not all remembered the name of their diagnosis. Participants described positive characteristics of health professionals, such as being flexible and able to adapt to patients' individual needs. Clinicians' strategies, such as normalizing patients' experiences, were usually perceived as supportive, but were not always considered helpful. After the diagnosis, participants were worried about potential social, practical, and philosophical issues.ConclusionThis research highlighted the importance of clinicians taking an exploratory and individualized approach to the sensitive process of disclosing a diagnosis related to diverse sex development to young adults. There are various strategies health professionals can use that might help young people to develop their knowledge about their condition: (1) repeating information to help the patient remember; (2) using language that is not too medicalized; and (3) communicating in a way that is meaningfully connected to patients' everyday lives.     

‘It's a good thing…’: Women's views on their continuity experiences with midwifery students from one Australian region

Backgroundmidwifery relationships, especially ones developed over time, are viewed and valued as practical and political health interventions that increase the likelihood of good health for women and infants and assist with health challenges. Thus the continuity relationships with women required for each Bachelor of Midwifery student are used, not only to expand students' learning but also, in a fragmented maternity care system, to provide opportunities for women to experience the care of a known person through their pregnancy, labour and early parenting time.Aim of the studywe sought understandings of women's experiences of their continuity relationships with midwifery students.Methoda survey was posted to all women (n=1008) who had agreed to continuity in the first years of our undergraduate program 2009–2011. We analysed 354 completed surveys (34% response rate). SPSS was used for quantitative data and content analysis identified themes expressed in the qualitative responses from a selected sub-set of 27 participants. Ethical approval was obtained from the authors' institution and research funding from the local registration board.Findingswomen's satisfaction of being with a student in a continuity relationship was high. On a scale from one (not at all satisfied) to 10 (extremely satisfied), the mean score was 8.88. The women, more than half of whom received standard maternity care, stated they valued the opportunity for a constant presence across their childbearing experience and will recommend student continuity to their friends.Conclusions and implicationsthis study shows that our curriculum emphasis on continuity is valued by women. Pairing a woman and a student gives women a relationship with a named person in the maternity health field that provides valued extras: care, time, patience, effort, information, advocacy, support and kindness. It raises the profile of midwifery in the community, especially the profile of continuity of midwifery care for women in standard models of care. It increases communication for and with women in a variety of useful and desirable ways and it allows an opportunity for women to contribute to students' learning. It also provides the university sector a chance to value and privilege the continuity of midwifery relationship.     

The Missing Uterus,the Missed Diagnosis,and the Missing Care. Mayer-Rokitansky-Küster-Hauser Syndrome in the Lives of Women in Malaysia

Study ObjectiveTo explore the effect of the diagnosis of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on affected Malaysian women.DesignQualitative study with a quantitative component.SettingPediatric and adolescent gynecology unit at Universiti Kebangsaan Malaysia Medical Centre, Malaysia.ParticipantsTwelve women with MRKH.InterventionsFace-to-face interview and short questionnaire.Main Outcome MeasuresThematic analysis was used to understand participants’ experiences.ResultsThere were 7 themes identified: (1) delayed diagnoses; (2) doctors' roles and attitudes; (3) gender identity; (4) family and society's response; (5) reaction toward infertility; (6) managing sexual intimacy; and (7) coping mechanisms. Several participants consulted their physicians regarding their primary amenorrhea at an opportunistic setting. When they were referred to the gynecologists, they were dismayed at the lack of information given. The term, “MRKH” plays an important role to ease information-seeking. Participants felt that the doctors were insensitive toward them. Mental illness is a significant complication of MRKH. All participants acknowledged that infertility was the hardest part of the condition. The importance of blood lineage affects their outlook on childbearing options. Some were afraid of sexual intimacy and worried that they would not be able to satisfy their partners. Participants gained support and bonded with their counterparts in the MRKH support group.ConclusionA multidisciplinary approach including medical, psychological, and social support is essential for the management of MRKH. Adequate information and sexual education plays the utmost importance in preventing social-related complications of MRKH.     

The lived experiences of midwifery care for women with diabetes: An integrative review

BackgroundMidwives provide care to women across the childbearing journey from pre-conception to the post-partum period in various clinical settings. Due to the increasing incidence of diabetic pregnancies, midwives are now in a position to support other health professionals, as part of a team, to reduce the stress and / or demand on the health care services.ObjectiveThis integrative review synthesises original research that explores the experiences and perceptions of midwives in the provision of care for women with diabetes.DesignIntegrative review.MethodsWhittemore and Knafl's (2005) systematic approach was used to search for primary literature related to the research question. Studies meeting the following criteria were included: primary qualitative, quantitative and mixed methods research studies published in peer reviewed journals between January 2009 to October 2019. The population of interest being midwives or nurse-midwives and the outcomes of interest included their perceived role in the management of women with diabetes from the pre conceptual to the postpartum period. The methodological quality of the studies was assessed using the appropriate CASP (Critical Appraisal Skills Programmes, 2014) criteria for qualitative and quantitative research studies. A robust search strategy was conducted using the following databases: EBCSO host (all data bases), Embase, Scopus, and Science Direct (see Table 1).FindingsA total of 7275 articles were retrieved and ten papers were included in this review (five qualitative and five quantitative) that fulfilled the inclusion criteria. Two overarching themes were identified: professional and personal impacts on midwifery practice. The professional impact theme included three sub themes: organisational issues, professional development and holistic support. The personal impact theme also included three themes: limited diabetes knowledge, limited clinical practice skills and mental attitude.Conclusions and implications for practiceThe findings indicate that midwives need opportunities to learn and develop skills specific to their role so that each individual's needs can be met. These opportunities include provision of education at a university level, offering work based training and increasing the number of post registration courses targeted at midwives who are willing to upskill to provide appropriate care to women with diabetes. Courses are required to address the knowledge, attitudes to diabetes, appropriate assessment skills and innovative communication skills for midwives.     

A Survey of Midwives in Quebec: What are Their Similarities and Differences?

Background: Until recently, Canada was the only industrialized country that had not legalized midwifery. In the province of Quebec the government adopted a law to evaluate midwifery in eight pilot projects before generalizing the practice. This study examined the similarities and differences among midwives in Quebec. Methods: Using data from a 1991 mail survey, we compared 31 nurse-midwives, 12 professional midwives, and 27 lay midwives to assess professional background and opinions about selected maternity care issues and aspects of future midwifery practice, such as midwife training options, responsibilities, setting for midwifery care, relationship to other maternity caregivers, autonomy, and control over their profession. Results: Midwives largely shared the same philosophy of care but had different viewpoints on two main professional aspects: compared with professional midwives and nurse-midwives, lay midwives preferred to deliver antepartum, intrapartum, and postpartum care at a client's home or an independent birthing center; like professional midwives, they rejected nursing as a prerequisite to midwifery training. Other interrelated personal, social, political, and legal factors were also associated with different beliefs. Conclusions: Despite the differences among the three groups, the process under way in Canada is to recognize a single profession of midwife. Creating a unified profession is a challenge that Canadian midwives with different backgrounds face in the 1990s.