Relationship between complementary and alternative medicine use and incidence of adverse birth outcomes: An examination of a nationally representative sample of 1835 Australian women

Objectivethere is evidence of high use of complementary and alternative medicine (CAM) by pregnant women. Despite debate and controversy regarding CAM use in pregnancy there has been little research focus upon the impacts of CAM use on birth outcomes. This paper reports findings outlining the incidence of adverse birth outcomes among women accessing CAM during pregnancy.Designa survey-based cohort sub-study from the nationally-representative Australian Longitudinal Study on Women׳s Health (ALSWH) was undertaken in 2010.Participantswomen (aged 31–36 years) who identified in 2009 as pregnant or recently given birth (n=2445) from the younger cohort (n=8012) of ALSWH were recruited for the study.Measurements and findingsparticipants׳ responses were analysed to examine the relationship between use of CAM and adverse birth outcomes from their most recent pregnancy. Of the respondents (n=1835; 79.2%), there were variations in birth outcomes for the women who used different CAM. Notably, the outcome which was most commonly associated with CAM use was emotional distress. This was found to occur more commonly in women who practised meditation/yoga at home, used flower essences, or consulted with a chiropractor. In contrast, women who consulted with a chiropractor or consumed herbal teas were less likely to report a premature birth, whilst participation in yoga classes was associated with an increased incidence of post partum/intrapartum haemorrhage.Key conclusionsthe results emphasise the necessity for further research evaluating the safety and effectiveness of CAM for pregnant women, with a particular focus on birth outcomes.Implications for practicehealth professionals providing care need to be aware of the potential birth outcomes associated with CAM use during pregnancy to enable the provision of accurate information to women in their care, and to assist in safely supporting women accessing CAM to assist with pregnancy, labour and birth.     

Women's experiences of labour and birth: an evolutionary concept analysis

Aim

the aim of this paper is to identify the core attributes of the experience of labour and birth.

Methods

a literature search was conducted using a variety of online databases for the years 1990–2005. A thematic analysis of a random sample of 62 of these papers identified the main characteristics of the experience of childbirth. There are multiple methodological challenges in researching the experience of labour and birth, and in developing the existing complexity of evidence.

Results

despite agreement across disciplines regarding the significance of the childbirth experience, there is little consensus on a conceptual definition. Four main attributes of the experience were described as individual, complex, process and life event. Through this concept analysis, the experiences of labour and birth is defined as an individual life event, incorporating interrelated subjective psychological and physiological processes, influenced by social, environmental, organisational and policy contexts.

Conclusions

identification of the core attributes of the labour and birth experience may provide a framework for future consideration and investigation including further analysis of related concepts such as 'support' and 'control'.

Implications for practice

practitioners and researchers have already identified the diversity and complexity of women's experiences during labour and birth. The importance of the identified attributes also requires organisational and policy development within the context of a cultural environment that acknowledges this diversity.     

Outcomes of independent midwifery attended births in birth centres and home births: A retrospective cohort study in Japan

Objective

the objective of this study was to describe and compare perinatal and neonatal outcomes of women who received care from independent midwives practicing home births and at birth centres in Tokyo.

Design

a retrospective cohort study.

Settings

birth centres and homes serviced by independent midwives in Tokyo.

Participants

of the 43 eligible independent midwives 19 (44%) (10 assisted birth at birth centres, nine assisted home birth) participated in the study. A total of 5477 women received care during their pregnancy and gave birth assisted by these midwives between 2001 and 2006.

Methods

researchers conducted a retrospective chart review of women’s individual data. Collected data included demographic characteristics, process of pregnancy and perinatal and neonatal outcomes. We also collected data about independent midwives and their practice.

Findings

of the 5477 women, 83.9% gave birth at birth centres and 16.1% gave birth at home. The average age was 31.7 years old and the majority (70.6%) were multiparas. All women had vaginal spontaneous deliveries, with no vacuum, forceps or caesarean section interventions. No maternal fatalities were reported, nor were breech or multiple births. The average duration of the first and second stages of labour was 14.9 hours for primiparas and 6.2 hours for multiparas. Most women (97.1%) gave birth within 24 hours of membrane rupture. Maternal position during labour varied and family attended birth was common. The average blood loss was 371.3 mL, while blood loss over 500 mL was 22.6% and over 1000 mL was 3.6%. Nearly 60% of women had intact perinea. There were few preterm births (0.6%) and post mature births (1.3%). Infant’s average birth weight was 3126 g and 0.5% were low-birthweight-infants, while 3.3% had macrosomia. Among primiparas, the birth centre group had more women experiencing an excess of 500 mL blood loss compared to the home birth group (27.2% versus 17.6% respectively; RR 1.54; 95%CI 1.10 to 2.16). Multiparas delivering at birth centres were more likely to have a blood loss over 500 mL (RR1.28; 95%CI 1.07 to 1.53) and over 1000 mL (RR1.75; 95%CI 1.04 to 2.82) compared to women birthing at home.

Conclusion

our results for birth outcomes with independent midwives at birth centres and home births in Japan indicated a high degree of safety and evidence-based practice. This study had some limitations because of its incomplete data and low response rate. However, this is one of the few studies that reported outcomes of Japanese independent midwives and the safety of their practice. A birth registry system would provide us with more accurate and complete information of all childbirths with which to evaluate the safety of independent Japanese midwives.     

Trauma during pregnancy: an analysis of maternal and fetal outcomes in a large population

OBJECTIVE: This study was undertaken to determine the occurrence rates, outcomes, risk factors, and timing of obstetric delivery for trauma sustained during pregnancy. STUDY DESIGN: This is a retrospective cohort study of women hospitalized for trauma in California (1991-1999). International Classification of Disease, ninth revision, Clinical Modification codes, and external causation codes for injury were identified. Maternal and fetal/neonatal outcomes were analyzed for women delivering at the trauma hospitalization (group 1), and women sustaining trauma prenatally (group 2), compared with nontrauma controls. Injury severity scores and injury types were used to stratify risk in relation to outcome. Statistical comparisons are expressed as odds ratios (ORs) with 95% CIs. RESULTS: A total of 10,316 deliveries fulfilling study criteria were identified in 4,833,286 total deliveries. Fractures, dislocations, sprains, and strains were the most common type of injury. Group 1 was associated with the worst outcomes: maternal death OR 69 (95% CI 42-115), fetal death OR 4.7 (95% CI 3.4-6.4), uterine rupture OR 43 (95% CI 19-97), and placental abruption OR 9.2 (95% CI 7.8-11). Group 2 also resulted in increased risks at delivery: placental abruption OR 1.6 (95% CI 1.3-1.9), preterm labor OR 2.7 (95% CI 2.5-2.9), maternal death OR 4.4 (95% CI 1.4-14). As injury severity scores increased, outcomes worsened, yet were statistically nonpredictive. The type of injury most commonly leading to maternal death was internal injury. The risk of fetal, neonatal, and infant death was strongly influenced by gestational age at the time of delivery. CONCLUSION: Women delivering at the trauma hospitalization (group 1) had the worst outcomes, regardless of the severity of the injury. Group 2 women (prenatal injury) had an increased risk of adverse outcomes at delivery, and therefore should be monitored closely during the subsequent course of the pregnancy. This study highlights the need to optimize education in trauma prevention during pregnancy.     

Pregnancy and birth outcomes of multiple gestations with PPROM occurred within 24 h after fetal reduction: A case series

ObjectiveThe study aims to analyze the pregnancy outcomes of multiple gestations with preterm premature rupture of membranes (PPROM) that occurred within 24 h after fetal reduction with potassium chloride (KCL).Materials and methodsWe identified and evaluated the outcomes of 16 retrospectively recorded multigestational pregnancies that met the inclusion criteria between 2006 and 2016, from the Obstetrics Department of Shandong Provincial Hospital. A total of 16 patients carrying twins or higher order multiple gestations experienced PPROM within 24 h after fetal reduction, and all of them received expectant management after understanding the relevant risks. The maternal and neonatal records were retrospectively collected and reviewed. Every surviving child was followed up to at least 2 years old.ResultOf the 16 cases, 12 cases (75%) ended in successful pregnancy, resulting in the delivery of at least 1 child surviving from a multiple gestational pregnancy. All cases of successful pregnancies were either term (≥37 weeks) or near-term (36⁺⁵ weeks) at delivery. And of those 20 infants delivered, only 3 were low birth weight infants (<2500g) (15%), None of the 16 women had fever, or other clinical symptoms and signs of chorioamnionitis during hospital stay. Postnatal follow-up of the surviving babies showed no obvious sequelae thus far. No newborn baby had neonatal complications, or needed to be transferred to neonatal intensive care unit.ConclusionOverall, our data demonstrate that dichorionic diamniotic (DCDA) twins or higher-order gestations who experienced PPROM of the reduced fetus within 24 h after selective reduction with KCL had relatively good outcomes with expectant management alone.     

The validity and reliability of the StationMaster: A device to improve the accuracy of station assessment in labour

Objective

To compare the accuracy of digital assessment and the StationMaster (SM) in the assessment of fetal head station. The SM is a simple modification of the amniotomy hook which works by relocating the point of reference for station assessment from the ischial spines to the posterior fourchette. It is first adjusted to the woman's pelvic size, and then inserted into the vagina until it touches the fetal head. The station is then read off at the posterior fourchette in cm.

Study design

An in vitro study of test validity and reliability was conducted at Liverpool Women's Hospital, Liverpool, UK. An apparatus was constructed in which a model fetal head could be accurately positioned within a mannequin's pelvis. Twenty midwives and 20 doctors (in current labour ward practice) gave their consent to take part. First, the head was placed in 5 random stations (−2 to +7 cm) and the participant asked to record their digital assessment for each. The participant was then taught to use the SM and the experiment repeated with 5 new stations. The complete experiment was repeated at least 2 weeks later using the same stations but in reverse order. The true values were compared with both the digital and SM assessments using mean differences with 95% limits of agreement. The repeatability of the two methods was assessed in the same way.

Results

Overall, the SM was more accurate than digital examination. The mean error (S.D.) ranged from 0.1 (1.2) to 2.6 (1.6) for the StationMaster and 0.3 (1.3) to 4.3 (1.1) for digital examination. Inaccuracies increased as the head descended through the pelvis. When assessed digitally, the true value fell outside one standard deviation for stations of more than +1 cm. In contrast, with the SM the true value remained inside one standard deviation for all stations up to +5.

Conclusions

In vitro the SM improves the accuracy of intrapartum station assessment.     

An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks

Objectivesin the Netherlands the perinatal mortality rate is high compared to other European countries. Around eighty percent of perinatal mortality cases is preceded by being small for gestational age (SGA), preterm birth and/or having a low Apgar-score at 5 minutes after birth. Current risk detection in pregnancy focusses primarily on medical risks. However, non-medical risk factors may be relevant too. Both non-medical and medical risk factors are incorporated in the Rotterdam Reproductive Risk Reduction (R4U) scorecard.We investigated the associations between R4U risk factors and preterm birth, SGA and a low Apgar score.Designa prospective cohort study under routine practice conditions.Settingsix midwifery practices and two hospitals in Rotterdam, the Netherlands.Participants836 pregnant women.Interventionsthe R4U scorecard was filled out at the booking visit.Measurementsafter birth, the follow-up data on pregnancy outcomes were collected. Multivariate logistic regression was used to fit models for the prediction of any adverse outcome (preterm birth, SGA and/or a low Apgar score), stratified for ethnicity and socio-economic status (SES).Findingsfactors predicting any adverse outcome for Western women were smoking during the first trimester and over-the-counter medication. For non-Western women risk factors were teenage pregnancy, advanced maternal age and an obstetric history of SGA. Risk factors for high SES women were low family income, no daily intake of vegetables and a history of preterm birth. For low SES women risk factors appeared to be low family income, non-Western ethnicity, smoking during the first trimester and a history of SGA.Key conclusionsthe presence of both medical and non-medical risk factors early in pregnancy predict the occurrence of adverse outcomes at birth. Furthermore the risk profiles for adverse outcomes differed according to SES and ethnicity.Implications for practiceto optimise effective risk selection, both medical and non-medical risk factors should be taken into account in midwifery and obstetric care at the booking visit.     

Womens' attitudes and beliefs of childbirth and association with birth preference: A comparison of a Swedish and an Australian sample in mid-pregnancy

Background

the rate of caesarean in Australia is twice that of Sweden. Little is known about women's attitudes towards birth in countries where the caesarean rate is high compared to those where normal birth is a more common event.

Objectives

to compare attitudes and beliefs towards birth in a sample of Australian and Swedish women in mid-pregnancy.

Participants

women from rural towns in mid Sweden (n=386) and north-eastern Victoria in Australia (n=123).

Methods

questionnaire data was collected from 2007 to 2009. Levels of agreement or disagreement were indicated on sixteen attitude and belief statements regarding birth. Principal components analysis (PCA) identified the presence of subscales within the attitudes inventory. Using these subscales, attitudes associated with preferred mode of birth were determined. Odds ratios were calculated at 95% CI by country of care.

Results

the Australian sample was less likely than the Swedish sample to agree that they would like a birth that: ‘is as pain free as possible' OR 0.4 (95% CI: 0.2–0.7), ‘will reduce my chance of stress incontinence' OR 0.2 (95% CI: 0.1–0.8), ‘will least affect my future sex life' OR 0.3 (95% CI: 0.2–0.6), ‘will allow me to plan the date when my baby is born' OR 0.4 (95% CI: 0.2–0.7) and ‘is as natural as possible' OR 0.4 (95% CI: 0.2–0.9). They were also less likely to agree that: ‘if a woman wants to have a caesarean she should be able to have one under any circumstances’ OR 0.4 (95% CI: 0.2–0.7) and ‘giving birth is a natural process that should not be interfered with unless necessary’ OR 0.3 (95% CI: 0.1–0.7). Four attitudinal subscales were found: ‘Personal Impact of Birth', ‘Birth as Natural Event', ‘Freedom of Choice' and ‘Safety Concerns'. Women who preferred a caesarean, compared to those who preferred a vaginal birth, across both countries were less likely to think of ‘Birth as a natural event’.

Key conclusions

the Australian women were less likely than the Swedish women to hold attitudes and beliefs regarding the impact of pregnancy and birth on their body, the right to determine the type of birth they want and to value the natural process of birth. Women from both countries who preferred caesarean were less likely to agree with attitudes related to birth as a natural event.     

Obesity and the placenta: A consideration of nutrient exchange mechanisms in relation to aberrant fetal growth

The obesity epidemic, including childhood obesity, is rapidly gaining strength as one of the most significant challenges to the health of the global community in the 21st Century. The proportion of women who are obese at the beginning of pregnancy is also increasing. These women and their babies are at high risk of pregnancy complications, and of programming for metabolic disease in adult life. In particular, maternal obesity is associated with aberrant fetal growth, encompassing both growth restricted and large for gestational age, or macrosomic fetuses. This article considers the potential effect of obesity and adipose tissue on placental nutrient exchange mechanisms in relation to aberrant fetal growth. The review emphasizes the dearth of work on this topic to date despite its importance to current and future healthcare of the population.     

Antepartum nonstress fetal heart rate monitoring: systematic analysis of baseline patterns and decelerations as an adjunct to reactivity in the prediction of fetal risks

A total of 1552 antepartum nonstress tests performed during the week before delivery are analyzed with respect to both reactivity and the presence of pathologic baseline patterns (tachycardia, bradycardia, diminished beat-to-beat variability) or decelerations. Correlation with mode of delivery and condition of the newborn infant shows that, irrespective of nonstress test reactivity, the presence of baseline anomalies and/or decelerations is associated with significantly increased perinatal morbidity and mortality. Nonstress test analysis, if systematic, that is, not restricted to reactivity alone, makes it possible to better detect fetuses at high perinatal risk, in which case closer surveillance would be indicated.     

Maternal serum biochemistry at 11-13(+6) weeks in relation to the presence or absence of the fetal nasal bone on ultrasonography in chromosomally abnormal fetuses: an updated analysis of integrated ultrasound and biochemical screening

BACKGROUND: Screening for trisomy 21 by a combination of maternal age, fetal nuchal translucency (NT) thickness and maternal serum free beta-hCG and pregnancy associated plasma protein-A (PAPP-A) at 11-13(+6) weeks of gestation is associated with a detection rate of 90%, for a false-positive rate of 5%. Recent evidence suggests that in about 70% of fetuses with trisomy 21 the nasal bone is not visible at the 11-13(+6) week scan and that the frequency of absence of nasal bone differs in different ethnic groups. In addition, there is a relationship between absent nasal bone and nuchal translucency thickness. In a preliminary study we showed that while PAPP-A levels were lower and free beta-hCG levels were higher in trisomy 21 fetuses with an absent nasal bone, this difference was not statistically different. In fetuses with trisomy 13 and trisomy 18, there is also a high (57 and 67%) incidence of an absent nasal bone. The aim of this present study was to extend our examination of whether the level of maternal serum biochemical markers is independent of the presence or absence of the nasal bone in cases with trisomy 21 and to ascertain if any differences exist in cases with trisomies 13 and 18. METHODS: This study data comprised 100 trisomy 21 singleton pregnancies at 11-13(+6) weeks of gestation from our previous study and an additional 42 cases analysed as part of routine OSCAR screening. A total of 34 cases with trisomy 18 and 12 cases with trisomy 13 were also available. Ultrasound examination was carried out for measurement of fetal NT and assessment of the presence or absence of the fetal nasal bone. Maternal serum free beta-hCG and PAPP-A were measured using the Kryptor rapid random access immunoassay analyser (Brahms Diagnostica AG, Berlin). The distribution of maternal serum free beta-hCG and PAPP-A in chromosomally abnormal fetuses with absent and present nasal bone was examined. RESULTS: The nasal bone was absent in 29 and present in 13 of the new trisomy 21 cases and in 98 (69%) and 44 respectively in the combined series. For the trisomy 18 cases, the nasal bone was absent in 19 (55.9%) cases and in 3 (25%) of cases of trisomy 13. There were no significant differences in median maternal age, median gestational age, NT delta, free beta-hCG MoM and PAPP-A MoM in trisomy 21 fetuses with and without a visible nasal bone, and similarly for those with trisomies 13 or 18. For a false-positive rate of 5%, it was estimated that screening with the four markers in combination with maternal age would be associated with a detection rate of 96% of cases with trisomy 21. For a false-positive rate of 0.5%, the detection rate was 88%. CONCLUSIONS: There is no relationship between an absent fetal nasal bone and the levels of maternal serum PAPP-A or free beta-hCG in cases with trisomies 13, 18 or 21. An integrated sonographic and biochemical test at 11-13(+6) weeks can potentially identify about 88% of trisomy 21 fetuses for a false-positive rate of 0.5%.