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.     

The changing role of indigenous lay midwives in Guatemala: New frameworks for analysis

Objectives

to examine the present-day knowledge formation and practice of indigenous Kaqchikel-speaking midwives, with special attention to their interactions with the Guatemalan medical community, training models, and allopathic knowledge in general.

Design/participants

a qualitative study consisting of participant-observation in lay midwife training programs; in-depth interviews with 44 practicing indigenous midwives; and three focus groups with midwives of a local non-governmental organization.

Setting

Kaqchikel Maya-speaking communities in the Guatemalan highlands.

Findings

the cumulative undermining effects of marginalization, cultural and linguistic barriers, and poorly designed training programs contribute to the failure of lay midwife-focused initiatives in Guatemala to improve maternal–child health outcomes. Furthermore, in contrast to prevailing assumptions, Kaqchikel Maya midwives integrate allopathic obstetrical knowledge into their practice at a highlevel.

Conclusions and implications

as indigenous midwives in Guatemala will continue to provide a large fraction of the obstetrical services among rural populations for many years to come, maternal–child policy initiatives must take into account that: (1)Guatemalan midwife training programs can be significantly improved when instruction occurs in local languages, such as Kaqchikel, and (2)indigenous midwives' increasing allopathic repertoire may serve as a productive ground for synergistic collaborations between lay midwives and the allopathic medical community.     

Satisfaction with planned place of birth among midwifery clients in British Columbia

The purpose of this study was to compare satisfaction with the birth experience among a population of women planning birth at home versus in hospital. In British Columbia, Canada, all midwives offer women meeting eligibility requirements for homebirth the choice to give birth in hospital or at home. Therefore, satisfaction can be attributed to planned place of birth, as the caregivers were the same in both settings. The mean overall score on the Labour Agentry Scale among women who had planned a homebirth (n = 550), 188.49 +/- 16.85, was significantly higher than those who planned birth in hospital (n = 108), 176.60 +/- 23.79; P < .001. Overall satisfaction with the birth experience was higher among women planning birth at home, 4.87 +/- 0.42 versus 4.80 +/- 0.49 on a scale of 1 to 5, although this difference was not statistically significant; P = .06. Among women whose actual place of birth was congruent with where they had planned, overall satisfaction was higher in the homebirth group, 4.95 +/- 0.20 versus 4.75 +/- 0.53; P < .001. Although satisfaction with the birth experience was high in both the home and hospital settings, women planning birth at home were somewhat more satisfied with their experience, particularly if they were able to complete the birth at home.     

How the integration of traditional birth attendants with formal health systems can increase skilled birth attendance

Background

Forty years of safe motherhood programming has demonstrated that isolated interventions will not reduce maternal mortality sufficiently to achieve MDG 5. Although skilled birth attendants (SBAs) can intervene to save lives, traditional birth attendants (TBAs) are often preferred by communities. Considering the value of both TBAs and SBAs, it is important to review strategies for maximizing their respective strengths.

Objectives

To describe mechanisms to integrate TBAs with the health system to increase skilled birth attendance and examine the components of successful integration.

Method

A systematic review of interventions linking TBAs and formal health workers, measuring outcomes of skilled birth attendance, referrals, and facility deliveries.

Results

Thirty-three articles met the selection criteria. Mechanisms used for integration included training and supervision of TBAs, collaboration skills for health workers, inclusion of TBAs at health facilities, communication systems, and clear definition of roles. Impact on skilled birth attendance depended on selection of TBAs, community participation, and addressing barriers to access. Successful approaches were context-specific.

Conclusions

The integration of TBAs with formal health systems increases skilled birth attendance. The greatest impact is seen when TBA integration is combined with complementary actions to overcome context-specific barriers to contact among SBAs, TBAs, and women.     

Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial)

Objectiveto explore the relationship between the degree to which labour is established on admission to hospital and method of birth.Backgrounda recent randomised controlled trial found fewer caesarean sections (CS) in women allocated to caseload midwifery (19.4%) compared with standard care (24.9%). There is interest in exploring what specific aspects of the care might have resulted in this reduction.Settinga large tertiary-level maternity service in Melbourne, Australia.ParticipantsEnglish-speaking women with no previous caesarean section at low risk of complications in pregnancy were recruited to a randomised controlled trial. Trial participants whose management did not include a planned caesarean and who were admitted to hospital in spontaneous labour were included in this secondary analysis of trial data (n=1532).Methodsthis secondary analysis included women admitted to hospital in spontaneous labour who were randomised to caseload midwifery compared with those randomised to standard care with regard to timing of admission in labour, augmentation of labour and use of epidural analgesia. In a further analysis randomised groups were pooled to examine predictors of caesarean section for first births only using multiple logistic regression.Resultsnulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4 cm compared with 5 cm in the caseload arm (p=0.012).Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively.Conclusionthese findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.     

Reclaiming birth, health, and community: midwifery in the Inuit villages of Nunavik, Canada

This article describes the Inuulitsivik midwifery service and education program, an internationally recognized approach to returning childbirth to the remote Hudson coast communities of Nunavik, the Inuit region of Quebec, Canada. The service is seen as a model of community-based education of Aboriginal midwives, integrating both traditional and modern approaches to care and education. Developed in response to criticisms of the policy of evacuating women from the region in order to give birth in hospitals in southern Canada, the midwifery service is integrally linked to community development, cultural revival, and healing from the impacts of colonization. The midwifery-led collaborative model of care involves effective teamwork between midwives, physicians, and nurses working in the remote villages and at the regional and tertiary referral centers. Evaluative research has shown improved outcomes for this approach to returning birth to remote communities, and this article reports on recent data. Despite regional recognition and wide acknowledgement of their success in developing and sustaining a model for remote maternity care and aboriginal education for the past 20 years, the Nunavik midwives have not achieved formal recognition of their graduates under the Quebec Midwifery Act.     

The landscape of caring for women: a narrative study of midwifery practice

Our purpose was to expand knowledge on the process and outcomes of midwifery care. Narrative analysis was used to interpret stories provided by midwives to illustrate their practice and recipients of midwifery care about their experience. A purposive sample of 14 midwives and four recipients of midwifery care was recruited as a subsample from a prior Delphi study on midwifery practice. Three broad themes were identified: 1) the midwife in relationship with the woman, 2) orchestration of an environment of care, and 3) the outcomes of care, called "life journeys" for the woman and the midwife. The findings are discussed from the perspectives of therapeutic landscapes described in cultural geography and prior research on midwifery practice. The challenge is to confirm the associations between the processes of care identified in these narratives with both short- and long-term outcomes in the health of women and their families. These appear to go well beyond the usual perinatal measures currently used in health care research and hold implications for how care is delivered, measured, and evaluated.     

Outcomes of planned home birth: an integrative review

Current evidence indicates the critical importance of several factors that contribute to improved perinatal outcomes: a facilitating environment at the place of birth, skilled birth attendance, and the continuum of perinatal care for women and newborns. This level of care is often referred to as "first-level" care, and is most readily provided in birthing centers and primary level health facilities. However, there is a body of evidence that has been compiled over the past several decades that addresses the safety of planned home birth, under circumstances that emulate these elements of "first-level" care. These studies demonstrate a remarkable consistency in the generally favorable results of maternal and neonatal outcomes, both over time and among diverse population groups. These outcomes are also favorable when viewed in comparison to various reference groups (birth center births, planned hospital births, and vital statistics). These data should influence policy in support of planned home birth, including policy that endorses building or sustaining a home birth infrastructure in parallel to the efforts to build capacity for facility-based birth. Such public policy would also be in keeping with the fundamental right of women to have choice in childbirth, particularly when options are equally good.     

Dissatisfaction with traditional birth attendants in rural Tanzania

Objective

To assess women's satisfaction with traditional birth attendants (TBAs) in rural Tanzania.

Method

A population-representative sample of households in Kasulu district was used to collect data on demographics, childbirth history, and perception of TBAs and doctors/nurses from women who had recently had a child and from their partners.

Results

Two-thirds of women who gave birth in a health facility reported being very satisfied with the experience, compared with 21.2% of women who delivered at home with TBAs. A sizeable proportion of women felt that TBAs had poor medical skills (23.1%), while only 0.3% of women felt the same about doctors' and nurses' skills. Of women who delivered with a TBA, 16.0% reported that TBAs had poor medical skills whereas 0.5% stated the same for doctors and nurses.

Conclusion

Although many women delivered at home in this rural study district, women and their partners reported higher confidence in doctors and nurses than in TBAs. Policymakers and program managers should not assume that women prefer TBAs to trained professionals for delivery but should consider system barriers to facility delivery in interventions aimed at reducing maternal mortality.     

A needs assessment study of traditional birth attendants in rural Kenya

For several reasons traditional birth attendants (TBAs) still deliver the majority of women in many developing areas of the world. A needs assessment study of TBAs serving one area of Kenya was conducted for the purpose of designing an appropriate intervention program. Thirty-six TBAs were interviewed. Together, they had attended to a total of 116 deliveries within 1 month. The local hospital was conducting an average of 37 deliveries per month. Although most TBAs were good at abdominal palpation, they did not conduct routine prenatal checks and rarely referred their clients to hospital. Several risky practices were identified from which a training program has been designed. The findings and their implications are discussed within the context of improved MCH/FP services.     

The confidence to practice midwifery: preceptor influence on student self-efficacy

The imperative for midwifery educators is to transmit to their students midwifery's unique body of knowledge and hallmarks of care that guide midwifery practice. Concerns have been raised about the ability to maintain the unique aspects of midwifery practice in a culture where routine use of intervention prevails. A theory-practice gap may lead to fewer student midwives exposed to the perspective and practices of midwifery during their clinical education. Preceptor role modeling is important to developing student confidence, conceptualized as self-efficacy, to persist in the practice of midwifery hallmark behaviors, particularly under conditions that undermine these practices. This study examined student perceptions of preceptor behaviors of two midwifery hallmarks of practice: therapeutic presence and non-intervention in the absence of complication and student self-efficacy for performing these behaviors. Recent graduates of education programs accredited by the American College of Nurse-Midwives Division of Accreditation completed researcher-developed tools regarding perceptions of preceptor behaviors of therapeutic presence and non-intervention and their outcome expectancy and self-efficacy for the same behaviors. The results indicate that preceptor behaviors influence student confidence to perform hallmark behaviors. Student belief in the value of the hallmark to benefit women is the biggest predictor of self-efficacy for hallmark behaviors. Clinical and educational implications and directions for future research are discussed.     

Keeping birth normal: research findings on midwifery care during childbirth

OBJECTIVE: This study describes processes and outcomes of midwifery care through narratives told by exemplary midwives. DESIGN: Narrative analysis. SETTING: Midwifery practices in hospital, birth center, and home settings. PARTICIPANTS: Purposive sample of 14 midwives drawn from a large national Delphi panel on exemplary midwifery practice. DATA ANALYSIS: Systematic analysis of interview data was conducted until interpretive consensus was achieved across all text and codes. Results were compared with two prior qualitative studies conducted by the first author on midwifery practice for congruence and emergence of new findings. RESULTS: The support of normalcy was identified as a significant process of midwifery care during labor and birth. CONCLUSIONS: The midwives believed that birth is normal, and many of their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process. Through their words, we see subtle care processes focused on meeting a woman's individual needs and tapping into her personal strength. Implications for practice and further research to link their approach to caring for women with perinatal outcomes are reviewed.