Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario

ObjectiveTo examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice.MethodsRetrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores.ResultsThe SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average.ConclusionThe SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.     

Prevalence and Factors Affecting Breastfeeding Among Aboriginal Women in Northwestern Ontario

ObjectiveTo evaluate breastfeeding outcomes among Aboriginal women and to determine variables affecting breastfeeding in the early postpartum period.DesignProspective cohort study.SettingTwo sites in Northwestern Ontario, Canada: a tertiary care center and a rural hospital.ParticipantsOne hundred thirty breastfeeding Aboriginal women agreed to participate in the study.MethodsAll women completed a baseline survey in hospital that included questions regarding demographic, prenatal, breastfeeding, obstetric, postpartum, and neonatal characteristics. Women were then telephoned at 4 and 8 weeks postpartum to complete additional questionnaires regarding infant feeding.ResultsLow rates of breastfeeding initiation (69%) and exclusive breastfeeding were identified at 4 (37.5%) and 8 (35.3%) weeks postpartum. Among those who initiated breastfeeding, duration rates at 4 (86%) and 8 weeks (78%) postpartum are comparable to other studies. Variables associated with any and exclusive breastfeeding at 8 weeks included the following: (a) household income, (b) intended breastfeeding duration, (c) plan to exclusively breastfeed, (d) perception of meeting their planned duration goal, and (e) higher breastfeeding self‐efficacy. Partner support was associated with any breastfeeding at 8 weeks but not exclusivity. Women who were breastfeeding exclusively in hospital (prevalence ratio [PR] = .48, 95% confidence interval [CI] [0.27, 0.86]), did not smoke (PR = 2.5, 95% CI [1.4, 4.3]) and/or use substances during pregnancy (PR = 4.5, 95% CI [1.5, 14]) were more likely to be breastfeeding exclusively at 8 weeks.ConclusionMany of the variables may be considered modifiable and amenable to intervention. Targeted interventions should be directed toward improving breastfeeding outcomes among Aboriginal women.     

Returning birth: The politics of midwifery implementation on First Nations reserves in Canada

Objective

to explore the role of midwives in the implementation of an elective birthing programme in one remote First Nation community in Canada, and to identify current barriers and challenges to the practice of midwifery in these settings

Design

the study is a multisited ethnography based on 15 months of fieldwork in Manitoba, Canada. Thirty-nine individual qualitative, semi-structured interviews were completed. The data from the interviews were coded into themes and presented in the paper.

Setting

the study focuses on one First Nation community and their process of implementation of midwifery services. This case study is used to address broader themes of midwifery and policy at a national level.

Participants

participants included Aboriginal midwives from across Canada, policy makers from provincial and federal jurisdictions, medical professionals involved in Aboriginal health care, Aboriginal political leadership, and Aboriginal women and their families.

Findings

national policy and issues of jurisdiction among levels of government were shown to be a barrier to midwifery implementation.

Key conclusions

the current policy of evacuation in most Aboriginal communities does not effectively address the Millennium Development Goal of having a skilled birth attendant at every birth. The role of midwifery is central to the process of returning birth to Aboriginal communities, and steps must be taken at both the policy and clinical level to ensure that midwifery implementation and education can become an option for all Aboriginal communities in Canada.

Implications for practice

when considering midwifery implementation in communities, midwives must engage in both political and clinical negotiations to ensure their ability to practice effectively. Understanding the complexity of the policy discourse, along with the place of midwifery within the existing clinical guidelines is integral to the success of this process.     

Maternal and Newborn Health Profile in a First Nations Community in Canada

ObjectiveWe sought to characterize maternal health profiles and birth outcomes among First Nations people living in Southern Ontario.MethodsWe performed a retrospective chart review of all 453 women from the Six Nations Reserve, Ontario, who were pregnant between 2005 and 2010. Maternal health behaviours, past medical history, physical measurements, birth outcomes, and newborn characteristics were abstracted. Key maternal and newborn characteristics were compared with those of a cohort of non-First Nations women recruited from nearby Hamilton, Ontario.ResultsThe average age of women in the study cohort was 25.1 ± 6.2 (mean ± SD) years, and 75.8% were multiparous. The mean pre-pregnancy BMI was 28.3 ± 6.6 kg/m², and the average weight gain in pregnancy was 14.9 ± 8.3 kg. Mean weight gain during pregnancy was inversely associated with pre-pregnancy BMI, and 57.1% of women gained more than the recommended weight. The prevalence of type 2 diabetes or gestational diabetes was 4.7%, hypertension was present before or during pregnancy in 5.6%, and 35% used tobacco during pregnancy. The mean gestational age at delivery was 39.5 ± 1.7 weeks and the mean crude birth weight was 3619 ± 557 g. The main determinants of newborn weight included sex of the newborn, pre-pregnancy BMI, and weight gain during pregnancy. Compared with a contemporary cohort of 622 non-First Nations mothers and newborns, First Nations mothers were, on average, younger (25.1 vs. 32.1 years; P< 0.001), had a higher mean pre-pregnancy BMI (28.3 vs. 26.8 kg/m²; P< 0.001), and were more likely to use tobacco during pregnancy (35.0% vs. 14.4%; P< 0.001). First Nations newborns had significantly higher mean birth weight (+176 grams) and length (+2.3 cm) than non-First Nations newborns.ConclusionFirst Nations mothers from the Six Nations Reserve tended to have a high pre-pregnancy BMI, tended to gain more than the recommended weight during pregnancy, and commonly used tobacco during pregnancy. Programs to prevent overweight/ obesity and excess weight gain during pregnancy and to minimize smoking are required among women of child-bearing age in this community.     

TRANSCULTURAL MIDWIFERY: Adapting to Hmong Birthing Customs in California

Nurse-midwifery care can adapt to incorporate birth customs and practices of immigrant groups seeking childbirth care. This paper explores birthing traditions among the Hmong, Laotian people. Fifteen Hmong men and women immigrants to Isla Vista, California were interviewed. The information gathered revealed the need to maintain traditional Hmong customs to facilitate both physical and emotional well-being during childbirth in the United States. Birthing and dietary traditions can be adapted within the hospital setting, if the nurse-midwife is aware of the need.     

Imagery and Symbolism in the Birth Practices of Traditional Cultures

ABSTRACT: In many traditional societies the childbirth environment is considered to be more powerful psychologically than physically. Sexual, simulative and religious imagery is employed to influence the parturient woman's feelings about the birth as a positive and active experience. The psychological assumptions involved appear to differ from western “natural” childbirth, and suggest a more holistic approach to birth experience.     

What Makes a Mother? Interviews With Women Involved in Egg Donatfon and Surrogacy

ABSTRACT: In recent years it has become possible to use eggs from one woman to bring about a pregnancy in another. This led to new dejinitions of who can be considered the mother of a child. Despite much speculation about the problems that may ensue from this situation, it is not at all clear that the women who have made the active decision to involve themselves in egg donation or gestational surrogacy will share these concerns. This paper reports on the interpretive frameworks used by 13 women who experienced either egg donation or gestational surrogacy, to defne their relationships to any children (actual or potential) conceived as a result of their actions. (BIRTH 21:2, June 1994)     

Wait Times for Women With Abnormal Uterine Bleeding in South-Western Ontario

ObjectiveWomen referred to an obstetrician-gynaecologist because of abnormal uterine bleeding (AUB) should be seen within 12 weeks, according to the benchmarks recommended for medically acceptable wait times established by the Society of Obstetricians and Gynaecologists of Canada. Our study aimed to determine the proportion of patients having wait times that meet this recommendation, and to understand patient-level sources of variation in these waits.MethodsWe performed a secondary analysis of data from the Delivering Primary Healthcare Information (DELPHI) project database. Electronic medical record data from 10 family practices across south-western Ontario were used to study AUB wait times.ResultsOver a 30-month period, 223 referrals were made to obstetrician-gynaecologists because of AUB. The mean wait time for initial assessment was 70.4 days (median = 51 days); the range among referring practices varied from 36 to 111 days. Seventy-one percent of women were seen by the obstetrician-gynaecologist within the recommended time of 12 weeks or less. Multi-level regression analysis indicated that older patients were more likely to have shorter waits. The intraclass correlation was 0.256, indicating that nearly a quarter of the variation in wait time was explained at the practice level.ConclusionNearly 30% of women referred to specialists because of AUB wait longer than the period of time recommended by the SOGC, with younger women more likely to wait longer. This difference may be due to the perception of an increased risk of malignancy in older women. Future research on correlates of AUB wait times should take factors such as severity and prior family physician work up into account.     

Decreasing Insulin Requirements in Pregnancy With Pre-existing or Gestational Diabetes: Management Practices Across Canada

Decreasing insulin requirements in pregnant women with preexisting or gestational diabetes has been attributed to placental insufficiency, which results in increased surveillance or early delivery. This practice is not evidence based. A 5-item questionnaire was administered electronically to a convenience sample of Canadian resident and staff obstetrician-gynaecologists and maternal–fetal medicine specialists. Practice patterns varied widely among the 142 survey respondents, and this variation did not correlate to their level of training. There is a paucity of evidence to guide the management of patients with decreasing insulin requirements, which is reflected in varied and possibly unnecessary clinical interventions.     

Traditional Practices of Women From India: Pregnancy, Childbirth, and Newborn Care

This article describes maternal and child care practices among women from India. As in all cultures, certain beliefs exist surrounding what facilitates a good pregnancy and its outcome, as well as negative sanctions. These practices continue to influence many immigrant women to whom western practices are either unknown or unacceptable. An understanding of the traditional belief system of such women can ease their adaptation into the Canadian and U.S. health care systems.     

Canadian Registered Midwives’ Experiences With Nipple Stimulation: An Exploratory Survey in British Columbia and Ontario

ObjectiveThe objective of our study was to explore Canadian registered midwives’ (RMs’) experiences with nipple stimulation.MethodsAn online survey was distributed to practising RMs in British Columbia and Ontario.ResultsIn total 350 RMs completed the survey. Of these, 154 (44%) practised in British Columbia and 196 (56%) practised in Ontario. This represents a response rate of 53.3% and 20.6% in B.C. and Ontario, respectively. Ninety-six percent of those surveyed (337 RMs) reported having advised clients to use nipple stimulation as a means of releasing oxytocin, and 80% (267 RMs) considered nipple stimulation to be effective. Respondents reported 926 protocols for nipple stimulation. The most common indication for nipple stimulation was for labour augmentation, used by 92% of respondents.ConclusionNipple stimulation is widely used by RMs practising in British Columbia and Ontario. Survey respondents believed it to be effective and beneficial in mitigating the need for synthetic oxytocin. Survey results showed that the most common indication for nipple stimulation is labour augmentation. Future research should prospectively address the safety and effectiveness of this non-medical method of labour augmentation.     

Congenital Urethrovaginal Fistula With Imperforate Hymen: A First Case Report

BackgroundCongenital urethrovaginal fistulas are rare, and all five reported cases have been associated with urogenital abnormalities. We describe a case of congenital urethrovaginal fistula with an imperforate hymen and no other urogenital abnormalities.CaseA 25-year-old female sought medical advice regarding cyclical hematuria, dyspareunia, and infertility of four years’ duration. Investigations disclosed a urethrovaginal fistula with an imperforate hymen. The patient was successfully treated with excision of the hymen and closure of the urethrovaginal fistula.ConclusionIn this instance, the diagnosis of congenital urethrovaginal fistula was delayed until adulthood because the presence of urinary incontinence, the usual presentation of a urethrovaginal fistula, was concealed by the imperforate hymen. We could find no previously reported case of urethrovaginal fistula with imperforate hymen.     

Models of Organizational Structure of Midwifery Practices Located in Institutions With Residency Programs

Four models of organizational structure for midwifery practices that are located in academic institutions with residency programs are described: parallel models, coexistence models, fully integrated models, and blended models. Examples of each of these models are presented along with advantages and disadvantages and overall effect on resident education.     

Age,Quality, and Context of First Sex: Associations With Sexual Difficulties

IntroductionResearch consistently indicates an association between a younger age at first sex and poorer sexual health outcomes. However, research addressing associations between age at first sex and sexual difficulties has produced mixed findings. Moreover, little is known about links between the context and quality of first sex and subsequent sexual difficulties.AimsThe aims of this study are to examine whether (i) age and (ii) context and quality at first sex are associated with sexual difficulties; (iii) examine whether age at first sex and context and quality variables are independently associated (after mutual adjustment) with sexual difficulties; and (iv) examine whether age at first sex has an indirect effect on sexual difficulties through an effect on context or quality.MethodsData from 388 questionnaires were gathered from students aged 17–21 living in accommodation halls and by postal invitation to adults aged 25–35.Main Outcome MeasuresThe main outcome measure was the Golombok–Rust Inventory of Sexual Satisfaction (GRISS), which assesses sexual difficulties via an overall score and seven subscales.ResultsAppraising first sex as emotionally negative was associated with the majority of sexual difficulties. A less stable relationship at first sex was associated with sexual communication problems and dissatisfaction. Greater enjoyment and using substances were associated with a lower likelihood of anorgasmia for women. Age at first sex was directly associated with reduced sexual frequency only. A younger age at first sex was associated with a greater likelihood of negative appraisal and lower likelihood of a stable relationship and thereby indirectly associated with several sexual difficulties.ConclusionsExperiencing first sex as emotionally negative was consistently associated with later sexual difficulties. When attending to sexual difficulties, understanding the quality and context of first sex may be more useful than knowing the age at first sex. This research is limited by the retrospective nature of the reports of first sex. Rapsey C. Age, quality, and context of first sex: Associations with sexual difficulties. J Sex Med 2014;11:2873–2881.     

First and Third Trimester Uterine Scar Thickness in Women With Previous Caesarean: A Prospective Comparative Study

Background

Lower uterine segment (LUS) thickness in the third trimester of gestation is associated with the risk of uterine scar defect at delivery. It was suggested that first trimester residual myometrial thickness (RMT) could also predict uterine scar defect at delivery.