Unique and proforma birth plans: A qualitative exploration of midwives׳ experiences

Background

birth plans detailing a woman?s preferences for intrapartum care are a common feature in British maternity units, and are a means of encouraging the implementation of choice. Proforma versions may be incorporated routinely in antenatal case notes, or the woman may devise her own unique birth plan. Although women?s views of birth plans have been explored, the views of midwives have not to date been evaluated. The growth of midwife-led units in the UK has highlighted different philosophies of care, some of which can be reflected in the different types of birth plan. Given the increasingly diverse nature of UK midwifery workplaces we set out to explore and compare the experience of midwives working in midwife-led and obstetric-led settings in relation to unique and proforma birth plans.

Method

qualitative study using focus groups of midwives in a midwife-led unit (MLU; n=5) and obstetric-led unit (OLU; n=4) in the East of England. We used an interpretative phenomenological analytical approach.

Findings

three main themes arose from the data. Firstly, the term ‘birth plan’ can be misleading, and was criticised for encouraging the belief that birth can be ‘planned’. In addition, midwives claimed that ‘unique’ birth plans, especially those influenced by some consumer advocacy groups, are becoming standardised in their rejection of policies and procedures and requests for intervention-free birth. Secondly, birth plans were a source of irritation for midwives in both groups, although the cause of the irritation differed between groups. Finally, it was found that midwives in both groups felt that birth plans put pressure on them, although again, the source of the pressure, and therefore the way in which midwives reacted to this pressure, differed between groups.

Conclusions

the term ‘birth plan’ can be misleading and create false expectations. If ‘unique’ birth plans are becoming ‘standardised’ in the sense that they routinely request the same things, they are little different to proforma birth plans. Some midwives perceive pressure both from women and the wider multidisciplinary team as a result of birth plans, a perception that causes some irritation.     

Cross-border-assisted reproduction: a qualitative account of UK travellers’ experiences

Surveys on patients’ experiences of cross-border fertility treatment have reported a range of positive and challenging features. However, the number of such studies is limited, and there is no detailed qualitative account of the experiences of UK patients who travel overseas for fertility treatment. The present study used a cross-sectional, qualitative design and in-depth interviews. Fifty-one participants (41 women and 10 men, representing 41 treatment ‘cases’) participated in semi-structured interviews. The experiences reported were broadly positive with a large proportion of participants (39 cases, 95%) citing a favourable overall experience with only two cases (5%) reporting a more negative experience. Thematic analysis revealed 6 major categories and 20 sub-categories, which described the positive and challenging aspects of cross-border fertility travel. The positive aspects were represented by the categories: ‘access’, ‘control’ and ‘care and respect’. The more challenging aspects were categorized as ‘logistics and coordination of care’, ‘uncertainty’ and ‘cultural dissonance’. The study confirms findings from others that despite some challenges, there is a relatively high level of patient satisfaction with cross-border treatment with participants able to extend the boundaries of their fertility-seeking trajectories and in some cases, regain a sense of control over their treatment.     

Oocyte donors’ experiences of altruistic known donation: a qualitative study

Objective: The purpose of this qualitative study was to investigate the experiences of women who had donated oocytes to a known recipient. Background: Altruistic known donation between friends or family members is the predominant form of oocyte donation in Canada due to legal prohibition of donor compensation. Methods: Data were collected from a hospital-based IVF clinic located in a Canadian city. Semi-structured interviews were audio-taped and transcribed verbatim. Results: Fifteen donors took part in the study either face to face or by phone interview. Among them, seven were a friend, six were a sister, one was a niece of the recipient, and one donated twice, once to her sister and once to a friend. Nine donations had resulted in a live birth – from newborn to seven years at the time of interview. Of these, four were intra-familial donation and five were friend-to-friend donation. Conclusions: The findings provide little evidence of relationship difficulties between donor and recipient during or following the donation and no evidence of coercion. Other than an altruistic desire to help a recipient and a self-evaluation of her own capacity to donate, the welfare of the intended child was in the mind of most donors during the decision-making phase.     

The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth

Background

Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness.

Methods

In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0.

Results

253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or ??red earth sand.?? Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill.

Conclusions

This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.     

Swedish midwives’ experiences and views of amniotomy: An interview study

ObjectiveTo explore midwives’ experiences and views of amniotomy.DesignA qualitative inductive design was used. Data were collected using interviews and analysed with content analysis carried out with NVivo 12.Setting and participantsSixteen midwives working at delivery wards at three hospitals in the south of Sweden.FindingsThree categories emerged: “Promote, protect and support the physiological process of labour”, “To make the decision -to do or not to do” and “Unpredictable response”. The overall theme linking the three categories was “We become our decisions”, portraying how midwives carry the responsibility in the decision-making and represent themselves in their handling of amniotomy.ConclusionsAmniotomy was experienced and viewed as both simple and complex, safe and risky, and deciding on it sometimes implied balancing contradicting perspectives. By using midwifery skills in the decision-making for an amniotomy, the midwives tried to predict the response, purposing to support physiological labour and promote health for women and babies.     

‘Luckily,I don't believe in statistics’: survey of women's understanding of chance of success with futile fertility treatments

Research questionWhy are women who face poor prognoses for success in assisted reproductive technology (ART) treatment choosing to pursue procedures using their own eggs, despite receiving information that their chances of success are very low.DesignCross-sectional study based on an anonymous questionnaire distributed to women aged between 43 and 45 years, undergoing ART using their own oocytes, at six public outpatient fertility clinics and three public in-hospital IVF units in Israel between 2015 and 2016. The main outcome measure was personal estimation of chance to achieve a live birth after the current ART treatment cycle and the cumulative estimated rate after all the treatment cycles the patient intended to undergo.ResultsResponse rate was 70.0%, with 91 participants of mean age 43.8 ± 0.7 years. Participants estimated their delivery rates after the next ART treatment cycle at 49.0 ± 31.8% (response rate 93.4%) and their cumulative delivery rates after all the ART treatments they would undergo at 57.7 ± 36.3% (response rate 90.1%). This is significantly higher than the predicted success rates of 5% and 15%, respectively (both P < 0.001), which are based on national register data. Nearly one-half of patients rated themselves as having a better than average chance of conception (47.3%).ConclusionWomen do not pursue futile treatments because they lack information. Despite being informed of the low success rates of conception using ART treatments, many patients of advanced maternal age have unrealistically high expectations from ART, essentially ignoring their estimated prognosis when deciding on treatment continuation. Future work should examine the psychological reasons behind continuing futile fertility treatments.     

Changing the future to change the past: women’s experiences of a positive birth following a traumatic birth experience

This paper reports on how women prepared for, experienced, and internalised a positive birth following a traumatic birth event. An interpretive phenomenological approach was adopted. Analysis was based on Gadamerian philosophical hermeneutics. Fourteen women were recruited through purposive sampling methods. Unstructured in‐depth interviews were conducted across two recruitment phases. The constitutive theme was ‘changing the future to change the past’. The birth stories illustrated how women changed their previous negative childbearing narratives through preparing for and experiencing a positive, joyful birth. Four key themes have been presented: ‘Resolving the past and preparing for the unknown’, ‘Being connected’, ‘Being redeemed’ and ‘Being transformed’. Participants included two women who ended their childbearing experiences with a traumatic birth. Exploration of differences between women who ended their childbearing experiences on trauma or joy has been offered to further develop a theory of redemption. The findings offer important insights into how women who have experienced birth trauma may be supported during a future pregnancy. Preparing women for uncertainty and providing opportunities for them to build trust in themselves and their caregivers may provide a bridge to a ‘redemptive’ experience. Women who do not experience a subsequent positive birth may need more specialised support.     

Primiparity: An ‘intermediate’ risk group for spontaneous and medically indicated preterm birth

Objective.?Most women in their first pregnancy are at ‘unknown’ risk for preterm birth. We hypothesized that such women may be at an increased risk for preterm birth in comparison to those with a prior term birth.

Methods.?We used Missouri's maternally-linked data (1989–97), comprised of women delivering their first singleton live birth (N = 259 431) and women delivering their first two consecutive singleton live births (N = 154 810). We compared preterm birth (<37 weeks) rates among women with a previous term birth, women with no reproductive history (primiparous women), and in those with a previous preterm birth. Risks of spontaneous and medically indicated preterm birth were also examined after adjustments for confounders through multivariate log-binomial regression models.

Results.?Preterm birth rates were 8.1%, 9.6%, and 23.3% among women with a previous term birth, among primiparous women, and among those with a previous preterm birth, respectively. In comparison to women with a prior term birth, risks of spontaneous preterm birth among primiparous women and among women with a prior preterm birth were 1.1-fold (95% confidence interval (CI) 1.0, 1.2) and 2.5-fold (95% CI 2.4, 2.6) higher, respectively. These risks were higher for medically indicated preterm birth among both primiparous women (RR 1.3, 95% CI 1.2, 1.4) and those with a prior preterm birth (RR 3.2, 95% CI 3.0, 3.5) than for spontaneous preterm births.

Conclusions.?Primiparous women are at increased risk of both medically indicated and spontaneous preterm birth. The findings suggest that studies on preterm birth should consider a risk assignment to include three groups: low-risk (prior term birth), intermediate risk (primiparity), and high-risk (prior preterm birth). This strategy will be informative for the identification of women with impending risk of delivering preterm, and complications associated with prematurity.     

When ART fails: figures,experiences, interventions and a plea for the ‘plan B’

Journal of Assisted Reproduction and Genetics - Infertility is perceived by many of those affected by it as one of the most stressful episodes in life. Assisted reproduction can help only some of...     

Cesarean or vaginal delivery for the breech fetus at the threshold of viability: results from a maternal–fetal medicine specialists survey

Objective.?To determine how United States Maternal–Fetal medicine specialists recommend delivery of a breech fetus at the threshold of viability.

Methods.?U.S. Society for Maternal–Fetal Medicine (SMFM) members were surveyed about; geographic location, practice type, whether they performed deliveries, definition of threshold for viability, recommendations for delivery of a breech fetus at the threshold of viability, and if the current medical–legal climate had any bearing on their decisions. Chi-Square and Fisher's Exact tests were used for analysis.

Results.?510 SMFM members responded to the questionnaire. The highest percentage of respondents stated ‘23 weeks’ (31%) as the cutoff for viability, followed by ‘24 weeks’ (21%) and ‘23 weeks or 500 g’ (10%). Seventy percent recommended cesarean delivery for a breech fetus at the threshold of viability. The majority of respondents based their decision on ‘published data’ or ‘expert opinion’, however, 58.6% reported they felt current medical evidence was inadequate to support a recommendation. Fifty-three percent stated their recommendations are affected by medical–legal concerns.

Conclusion.?The majority of U.S. maternal fetal–medicine specialists who responded would recommend cesarean delivery for a breech fetus at the threshold of viability, despite the belief that there is inadequate evidence in the literature to support this recommendation.     

Surrogates’ and intended parents’ experiences of surrogacy arrangements: a systematic review

This commentary situates the recently published systematic review of empirical studies of surrogates’ and intended parents’ experiences of surrogacy by Kneebone, Beilby and Hammarberg within the context of increased international interest in legislative and regulatory reforms to surrogacy. The commentary evaluates the strengths of this systematic review, before turning to a discussion of how jurisdictions could introduce reforms aiming to facilitate domestic surrogacy arrangements, focusing on the UK and the Law Commission's recent proposals.     

Italian psychologists’ and midwives’ perceptions of the pregnant teen: a qualitative study

Background: Although debate on adolescent pregnancies has continued for many years, only a few studies have paid attention to the attitudes of health workers and their perceptions of these teens. Objective: The main purpose of this study was to investigate and describe midwives’ and psychologists’ perceptions of the pregnant teens arriving at the health centres – either who wanted to become mothers or to interrupt pregnancy – analysing health workers’ reflections on their experiences of caring for these teens during pregnancy in the Italian context. Methods: Interviews were conducted with 22 health workers in order to describe their perceptions of Italian pregnant adolescents. Interviews were analysed using thematic analysis. Results: Data analysis identified three themes arising from health workers narrations: ‘teen identities’, with the subthemes confused teens, omnipotent teens and immigrant teens; ‘maternal bonding’, with the subthemes supportive mothers and self-centred mothers; and ‘social support demand’, with the subthemes support-seeking teens, self-excluded teens and unsupportive young partners. Conclusion: The results provide an interesting picture of health workers’ perceptions of Italian pregnant adolescents adding new knowledge that will be useful for better planning interventions with pregnant teenagers.     

Tensions and conflicts in ‘choice’: Womens’ experiences of freebirthing in the UK

Backgroundthe concept of choice is a central tenet of modern maternity care. However, in reality women’s choice of birth is constrained by a paucity of resources and dominant medical and risk adverse discourses. In this paper we add to this debate through highlighting the tensions and conflicts that women faced when enacting a freebirthing choice.Methodssecondary analysis of data collected to explore why women choose to freebirth in the UK was undertaken. Ten women were recruited from diverse areas of the UK via invitations on freebirthing websites. Women provided a narrative and/or participated in an in-depth interview. A thematic analysis approach was used.Findingswe present three key themes. First ‘violation of rights’ highlights the conflicts women faced from maternity care systems who were unaware of women’s legal rights to freebirth, conflating this choice with issues of child protection. ‘Tactical planning’ describes some of the strategies women used in their attempts to achieve the birth they desired and to circumnavigate any interference or reprisals. The third theme, ‘unfit to be a mother’ describes distressing accounts of women who were reported to social services.Conclusion and implications for practicewomen who choose to freebirth face opposition and conflict from maternity providers, and often negative and distressing repercussions through statutory referrals. These insights raise important implications for raising awareness among health professionals about women’s legal rights. They also emphasise a need to develop guidelines and care pathways that accurately and sensitively support the midwives professional scope of practice and women’s choices for birth.     

‘Not a primrose path’: Commissioning parents' experiences of surrogacy arrangements in Britain

Abstract

The introduction into UK legislation on 1 November 1994 of Section 30 of the Human Fertilisation and Embryology Act 1990 was the direct consequence of a married couple seeking to establish their parental responsibility for their genetic twins born to a surrogate mother. Whilst there has been considerable debate in the UK and elsewhere concerning the desirability or otherwise of surrogacy, the arguments for and against its regulation, and its impact on surrogate mothers, commissioning parents and children born following a surrogacy arrangement, little accurate knowledge concerning surrogacy arrangements has been available to inform either this debate or aid policy development. This paper provides information from interviews with commissioning parents undertaken as part of an exploratory empirical study of surrogacy arrangements in the UK, and complements an earlier account of the experiences of surrogate mothers (Blyth, 1994).     

Cervical cerclage and type of suture material: a survey of UK consultants’ practice

Abstract

Objective: The main aim of the survey was to explore current practices with regards to cervical cerclage procedures amongst UK consultants with particular emphasis on the type of suture material used.

Methods: An electronic survey of UK consultant members and fellows of the Royal College of Obstetricians and Gynaecologists and who previously agreed to be contacted for survey purposes.

Results: There were 261 respondents to the survey and 88% routinely performed cerclage. The majority performed the procedure between 12 and 16 weeks’ gestation (88.7%; n?=?180/203), following the McDonald technique (83.4%; n?=?166/199) and using a braided suture material (86.6%; n?=?175/202). Although only 27 of the 202 responders (13.4%) used a monofilament suture for cerclage (75%; n?=?149/201) of clinicians stated that they were not sure what is the best suture material to be used.

Conclusion: There is considerable variation in practice amongst Consultant obstetricians with regards to cervical cerclage. Although most respondents use the traditional braided suture material, a significant proportion of them were not sure what is the best suture material to use. The “gestation at delivery” rate was judged to be the most important outcome for a future study.     

‘Female condoms give women greater control’: A qualitative assessment of the experiences of commercial sex workers in Swaziland

ABSTRACT

Objectives To explore commercial sex workers’ experiences with the female condom in Swaziland.

Methods This is a qualitative study that draws on two focus group discussions and ten individual in-depth interviews with female commercial sex workers in Lavumisa, Swaziland.

Results The findings suggest that the majority of female sex workers prefer to use the female condom with their clients because it offers them greater control over the sexual encounter. Other factors that facilitate its use include the absence of side effects, the enhancement of sexual pleasure and protection against the risk of STIs (including HIV). In addition, the women reported that the female condom is stronger and more resistant to breakage than the male condom. Moreover, the female condoms can be inserted well in advance of sexual intercourse. Difficulties of insertion, partner objection and limited product availability were some of the barriers to the use of the device. There was also a tendency to reuse the female condoms because of lack of product availability and privacy to insert it.

Conclusion Although female condom use involves negotiation with clients, the fact that it offers sex workers an independent method of protection gives them more power and also, increases their ability to control their sexual and reproductive health.     

Midwives’ experiences of asking the Whooley questions to assess current mental health: a qualitative interpretive study

Backgound: Perinatal Mental Illness (PMI) is a key cause of maternal mortality and morbidity in the UK, with one goal of midwives to identify those at risk during pregnancy. At present, the system of preliminary identification of existing PMI in the UK involves the midwife asking pregnant women the Whooley questions at the antenatal booking interview. Aim: To explore midwives experiences of asking the Whooley questions with pregnant women. Method: A qualitative interpretive study explored midwives’ (n = 8) experiences of asking the Whooley questions in one maternity unit in England (UK). Data were gathered through semistructured interviews and analysed using Framework Analysis (FWA). Findings: Themes and subthemes identified included: (1) no clear understanding of purpose, (1a) discomfort when disclosure occurs, (2) feeling pressurised for time, (3) resultant dissatisfaction and frustration; (3a) lack of knowledge and how to refer, (3b) lack of training around PMI, (3c) relying on experience and use of intuition. Discussion: The development and evaluation of an education curriculum to prepare midwives to effectively use case-finding instruments such as the Whooley questions to identify pregnant women at risk is required.