Approaches to assessment of alcohol intake during pregnancy in Swedish maternity care—a national-based investigation into midwives’ alcohol-related education,knowledge and practice

Objective

to evaluate how much education midwives in Sweden have undertaken to help them assess alcohol intake during pregnancy, and what tools they use to identify women who may be at risk of drinking during pregnancy.

Design

a national survey was conducted in March 2006, using a questionnaire constructed by a Swedish team of researchers and clinicians.

Setting

maternity health-care centres in Sweden.

Participant

2106 midwives.

Findings

nearly all midwives stated that they had excellent or good knowledge concerning the risks associated with drinking during pregnancy. They considered themselves less knowledgeable about detecting pregnant women with risky alcohol consumption before pregnancy. The majority of the midwives had participated in some education in handling risky drinking. Almost half of the midwives assessed women's alcohol intake before pregnancy. Important facilitators for increased activity concerned recommendations and decisions at different levels (national, local and management) on how to address alcohol with expectant parents and work with risky drinkers.

Key conclusions

more education was associated with more common use of a questionnaire for assessment of women's alcohol intake before pregnancy, and more frequent counselling when identifying a pregnant woman whose pre-pregnancy consumption was risky.     

Influence on birthing positions affects women's sense of control in second stage of labour

Objective

to explore whether choices in birthing positions contributes to women's sense of control during birth.

Design

survey using a self-report questionnaire. Multiple regression analyses were used to investigate which factors associated with choices in birthing positions affected women's sense of control.

Setting

midwifery practices in the Netherlands.

Participants

1030 women with a physiological pregnancy and birth from 54 midwifery practices.

Findings

in the total group of women (n=1030) significant predictors for sense of control were: influence on birthing positions (self or self together with others), attendance of antenatal classes, feelings towards birth in pregnancy and pain in second stage of labour. For women who preferred other than supine birthing positions (n=204) significant predictors were: influence on birthing positions (self or self together with others), feelings towards birth in pregnancy, pain in second stage of labour and having a home birth. For these women, influence on birthing positions in combination with others had a greater effect on their sense of control than having an influence on their birthing positions just by themselves.

Key conclusions

women felt more in control during birth if they experienced an influence on birthing positions. For women preferring other than supine positions, home birth and shared decision-making had added value.

Implications for practice

midwives can play an important role in supporting women in their use of different birthing positions and help them find the positions they feel most comfortable in. Thus, contributing to women's positive experience of birth.     

Midwives' knowledge of,attitudes towards and experiences of caring for women with intellectual disability during pregnancy and childbirth: A cross-sectional study in Sweden

Objective

to investigate midwives' knowledge of, attitudes towards and experiences of caring for women with intellectual disability (ID) during pregnancy and childbirth.

Design/setting

a cross-sectional study among six hundred midwives working at antenatal care and labour wards in Sweden.

Results

more than four out of five (81.5%) midwives had experience of caring for women with ID. Almost all midwives (97.1%) reported that caring for women with ID is different from caring for women without ID. Almost one-half (47.3%) had not received any education about pregnancy and delivery of women with ID, and a majority of the midwives (95.4%) requested evidence-based knowledge of women with ID in relation to childbirth. High proportion (69.7%) of the midwives were of the opinion that women with ID cannot satisfactorily manage the mother role, and more than one-third (35.7%) of the midwives considered that women with ID should not be pregnant and give birth at all. Most midwives partly/totally agreed that children of women with ID should grow up with their parents supported by the social authorities, but nearly one-fifth (19.1%) partly/totally agreed that the children should grow up in foster care.

Conclusions

even if the majority of midwives had experience of caring for women with ID, they were uncertain about how to adapt and give advice and they needed more knowledge about these women. Some midwives had negative attitudes towards childbearing among women with ID. Health Service providers should encourage midwives to update their knowledge and provide supportive supervision in midwifery care for women with ID.     

Somali women's experience of childbirth in the UK: Perspectives from Somali health workers

Objective

to conduct a qualitative study of perceptions of experiences of childbirth from Somali health workers in the UK.

Design &; setting

in depth narrative interviews at community centres and places of work in London.

Participants

eight Somali women aged between 23 and 57 years. The interviewees worked within the health sector in the UK and/or as nurses or gynaecologists in Somalia. Six of the women had also given birth in the UK.

Key findings

mismanagement of care of female circumcision provided during pregnancy and labour leads to problems at birth for many Somali women. The importance of Somalia's oral culture is not recognised when addressing communication barriers and continuity of care is lacking but important. Somali women also felt that midwives held stereotyped and negative attitudes towards them. Existing pressures as a consequence of migration were compounded by these experiences of childbirth in the UK.

Key conclusions

issues concerning female circumcision, verbal communication, cultural aspects of care and pressures that were a consequence of migration play a part in the experience of childbirth in the UK for Somali women.

Implications for practice

midwives need to possess the necessary clinical knowledge and skills to deal with women who have been circumcised and the issue needs to be raised early in the pregnancy. Attention needs to be paid to ensure continuity of care, maximising verbal communications and challenging stereotypical views of Somali women.     

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.     

The relationship between women-centred care and women's birth experiences: a comparison between birth centres, clinics, and hospitals in Japan

Objective

the goal of women-centred care (WCC) is respect, safety, holism, partnership and the general well-being of women, which could lead to women's empowerment. The first step in providing WCC to all pregnant women is to describe women's perceptions of WCC during pregnancy in different health facilities. The objectives of this study were to ask (a) what are the perceptions and comparison of WCC at Japanese birth centres, clinics, and hospitals and (b) what are the relationships between WCC and three dimensions of women's birth experience: (1) satisfaction with care they received during pregnancy and birth, (2) sense of control during labour and birth, and (3) attachment to their new born babies.

Design

this was a cross-sectional study using self-completed retrospective questionnaires.

Setting

three types of health facility: birth centres (n=7), clinics (n=4), and hospitals (n=2).

Participants

participants were women who had a singleton birth and were admitted to one of the study settings. Women who were seriously ill were excluded. Data were analysed on 482 women.

Measurements

instrumentation included: a researcher-developed WCC-pregnancy questionnaire, Labour Agentry Scale, Maternal Attachment Questionnaire, and a researcher-developed Care Satisfaction Scale.

Findings

among the three types of settings, women who delivered at birth centres rated WCC highly and were satisfied with care they received compared to those who gave birth at clinics and hospitals. WCC was positively associated with women's satisfaction with the care they received.

Key conclusions

women giving birth at birth centres had the most positive perceptions of WCC. This was related to the respectful communication during antenatal checkups and the continuity of care by midwives, which were the core elements of WCC.

Implications for practice

health-care providers should consider the positive correlation of WCC and women's perception of satisfaction. Every woman should be provided continuity of care with respectful communication, which is a core element of WCC.     

Making physiological birth possible: Birth at a free-standing birth centre in Berlin

Background

the practical training in midwifery education in Germany takes place predominantly in hospital delivery wards, where high rates of intervention and caesarean section prevail. When midwives practice birth assistance at free-standing birth centres, they have to make adjustments to what they learned in the clinic to support women without the interventions common to hospital birth.

Objectives

the primary aim of this study was to investigate and describe the approach of midwives practicing birth assistance at a free-standing birth centre.

Methodology

a qualitative approach to data collection and analysis with grounded theory was used which included semi-structured expert interviews and participant observation. Five midwives were interviewed and nine births observed in the research period. The setting was a free-standing birth centre in a large German city with approximately 115 births per year.

Findings

the midwives all had to re-learn birth assistance when commencing work outside of the hospital. However, having been trained predominantly in hospital maternity wards, they have retained many aspects characteristic of their training. The midwives use technology, although minimal, and medical discourse in combination with 1:1, woman-centred care. The birthing woman and midwife share authority at birth. The fetus is treated as an ally of the mother, suited for birth and cooperative. Through use of objective and subjective criteria, the midwives have their own approach to making physiological birth possible.

Key conclusions and implications for practice

to prepare midwives to support low-intervention birth, it is necessary to include training in birth assistance with women who birth physiologically, without interventions common to hospital birth. The results of this study would also suggest that the rate of interventions in hospital could be reduced if midwives gain more experience with women birthing without the above-mentioned interventions.     

A qualitative investigation of alcohol use advice during pregnancy: Experiences of Dutch midwives,pregnant women and their partners

Objective

two studies aimed to explore the advice Dutch midwives give and the information Dutch pregnant women and partners of pregnant women receive about alcohol consumption in pregnancy.

Design

study 1 included individual semi-structured interviews with midwives. Study 2 involved focus groups and individual semi-structured interviews with pregnant women and partners. Interview content was based on the I-Change Model.

Setting

study 1 was conducted nation-wide; Study 2 was conducted in the central and southern regions of the Netherlands.

Participants

10 midwives in Study 1; 25 pregnant women and nine partners in Study 2.

Measurements and findings

study 1 showed that midwives intended to advise complete abstinence, although this advice was mostly given when women indicated to consume alcohol. Midwives reported to lack good screening skills and sufficient knowledge about the mechanisms and consequences of antenatal alcohol use and did not involve partners in their alcohol advice. In Study 2, the views of pregnant women and partners were congruent to the findings reported in Study 1. In addition, pregnant women and partners considered midwives as an important source of information on alcohol in pregnancy. Partners were interested in the subject, had a liberal view on antenatal alcohol use and felt ignored by midwives and websites. Pregnant women indicated to receive conflicting alcohol advice from their health professionals.

Key conclusions

midwives' alcohol advice requires improvement with regard to screening, knowledge about mechanisms and consequences of antenatal alcohol use and the involvement of the partners in alcohol advice during pregnancy.

Implications for practice

training should be given to Dutch midwives to increase their screening skills and their alcohol related knowledge to pregnant women. Research is needed to determine how the midwife's alcohol advice to the partner should be framed in order to optimise the partner's involvement concerning alcohol abstinence in pregnancy. More attention to the topic at a national level, for example via mass media campaigns, should also be considered to change views about alcohol use during pregnancy in all stakeholders.     

What can qualitative studies tell us about the experiences of women who are pregnant that have an eating disorder?

Objective

pregnancy is a life-stage during which women undergo significant changes to their body and can feel acute responsibility for the development and well-being of the fetus. A synthesis of qualitative studies was conducted to increase our understanding of pregnancy experiences among women with an eating disorder.

Design

a systematic search of eight electronic databases was carried out to identify relevant investigations. Studies were appraised by two authors. Data were combined using framework analysis. From 459 references, seven papers were included in the review.

Findings

an overriding concept of inner turmoil transpired from the synthesis. This personal conflict related to the fear and guilt expressed by interviewees and stemmed from their association of self-worth with their body, concerns about their child's health and worries about others' response to their eating and weight control practices.

Key conclusions

participants reported vacillating between wanting to do the best for their child, being motivated by social pressures and feeling the need to control their body for self-preservation purposes. This created the inner turmoil they experienced while pregnant.

Implications for practice

midwives should be sensitive to the possibility of an eating disorder among pregnant women. In such cases, practitioners could act as a conduit for any assistance required, guiding these mothers towards appropriate nutritional and psychological support. To do this, professionals must have knowledge of such conditions and be aware of services available for women disclosing disordered eating behaviours.     

Women want proactive psychosocial support from midwives during transition to motherhood: a qualitative study

Objective

to explore low-risk pregnant women's views on their preferences for psychosocial support from midwives during their transition to motherhood.

Design

a qualitative design with focus-group interviews and thematic analysis of the discussions.

Settings and respondents

21 Dutch participants were included in three focus groups. Groups 1 (n=7) and 3 (n=8) consisted of pregnant women from four semi-urban midwifery practices, and group 2 (n=6) included participants from three urban midwifery practices.

Findings

the women wanted to take responsibility for their own well-being during pregnancy. In addition to informal support, they explicitly expressed a need for professional support from their midwives when undergoing the transition to motherhood. They wanted informational and emotional support from their midwives that addressed psychological and physical changes during pregnancy. They expressed a strong desire to be informed during pregnancy of how to prepare physically and psychologically for birth, recovery and motherhood. They also wanted help with sifting and interpreting information and, ultimately, wanted to make their own choices.

Key conclusions and implications for practice

during their transition to motherhood, healthy low-risk pregnant women want attentive, proactive, professional psychosocial support from midwives. They expect their midwives to oversee the transition period and to be capable of supporting them in dealing with changes in pregnancy and in preparing for birth and motherhood.     

'Soothing the ring of fire': Australian women's and midwives' experiences of using perineal warm packs in the second stage of labour

Objective

to determine women's and midwives’ experiences of using perineal warm packs in the second stage of labour.

Design

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

Setting

two hospitals in Sydney, Australia.

Participants

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

Intervention

warm, moist packs were applied to the perineum in the late second stage of labour.

Findings

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

Key conclusions

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

Implications for practice

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.     

Prenatal attachment and associated factors during the third trimester of pregnancy in Temuco, Chile

Objective

to estimate the prevalence of poorer prenatal attachment and its association with psycho-affective factors in pregnant women during the third trimester.

Design and setting

cross-sectional study in Temuco, La Araucanía Region, Chile.

Measurements

data were collected by structured interview with closed questions for the sociodemographic characterisation of the sample and measurement of six aspects: prenatal attachment, perceived stress, depression, perception of relationship with partner, subjective family support, and obstetric information regarding current and previous pregnancies.

Participants

244 pregnant women selected by stratified random sampling in all centres (n=5) of the public health system in Temuco, Chile, with proportional allocation.

Findings

the prevalence of poorer prenatal attachment was 24.3% (95% confidence interval 19–30%), and this was found to be associated with discontent with the pregnancy, unwanted pregnancy, higher levels of perceived stress, depression and low family support. Religious activity and work were found to modulate the association between poorer prenatal attachment and psycho-affective aspects. The percentage of unplanned pregnancies was high in this study (61.35), and although this does not have a direct influence on poorer prenatal attachment, it is associated with discontent with the pregnancy and unwanted pregnancy.

Key conclusions and implications for practice

the high proportion of poorer prenatal attachment during the third trimester of pregnancy associated with potentially detectable psychosocial factors means that early diagnosis and timely intervention during prenatal care are an essential challenge for midwives in their work. Any progress that can be made during pregnancy will favour the development of the bonding experience after birth, and thus the balanced development of the child.     

Professional and social support enhances maternal well-being in women with intellectual disability – A Swedish interview study

Objective

to gain a deeper understanding of the experience of professional and social support during pregnancy and childbirth among women with intellectual disability (ID) in Sweden.

Design/setting

an interview study among 10 women with ID, who had given birth within seven years. Two interviews were performed with each woman and data were analysed with qualitative content analysis.

Findings

the overarching theme was: Professional and social support enhances maternal well-being in women with intellectual disability. The women described that the midwife and other caregivers contributed to their own insights and supported their mother-to-be process. They were mostly satisfied with the professional care and support during pregnancy and childbirth, based on aspects such as continuity, competence and professional experience of the midwives but also professional approach and working methods. Dissatisfaction and confusion occurred when questions were left unanswered or when the women?s special needs were not taken into consideration. Family members, friends and colleagues could also have a supporting role and, together with the health staff, contribute to the well-being of the woman.

Conclusions

if professional support and care from midwives and other caregivers is adapted to the special needs of women with ID, it contributes to new insights, enhances well-being and supports the process of becoming a mother. Midwife-led continuity of care together with continuous social support should be offered to pregnant women with ID during pregnancy and childbirth.     

Why home birth? A qualitative study exploring women's decision making about place of birth in two Canadian provinces

Objective

the aim of this study was to increase our understanding of why Canadian women choose to give birth at home. Despite on-going debate regarding the safety of home birth, a small number of Canadian women choose home as a place to give birth. The factors influencing a woman's decision to plan a home birth remain poorly understood.

Design

a qualitative, grounded theory approach using semi-structured interviews.

Participants

a purposive sample of women from two Canadian provinces, who planned to give birth at home in their current pregnancy or who had planned a home birth within the last 2 years.

Findings

thematic analysis highlighted key motivating factors as well as a decision-making framework by which women chose home birth. The decision making process includes an exploration of internal motivators for wanting home birth, a phase of information gathering and taking ownership for the decision to give birth at home.

Key conclusions

the study showed that women in two geographically distinct parts of Canada approach decision making around home birth in a similar fashion and provides a framework for decision making for choosing to birth at home.

Implications for practice

improved understanding of the decision making process for choice of birth place is useful for midwives for the provision of information to their clients and for midwifery policy and practice within Canada.     

The hardware and software implications of hospital birth room design: A midwifery perspective

Objective

to explore the impacts of physical and aesthetic design of hospital birth rooms on midwives.

Background

the design of a workplace, including architecture, equipment, furnishings and aesthetics, can influence the experience and performance of staff. Some research has explored the effects of workplace design in health care environments but very little research has examined the impact of design on midwives working in hospital birth rooms.

Methods

a video ethnographic study was undertaken and the labours of six women cared for by midwives were filmed. Filming took place in one birth centre and two labour wards within two Australian hospitals. Subsequently, eight midwives participated in video-reflexive interviews whilst viewing the filmed labour of the woman for whom they provided care. Thematic analysis of the midwife interviews was undertaken.

Findings

midwives were strongly affected by the design of the birth room. Four major themes were identified: finding a space amongst congestion and clutter; trying to work underwater; creating ambience in a clinical space and being equipped for flexible practice. Aesthetic features, room layout and the design of equipment and fixtures all impacted on the midwives and their practice in both birth centre and labour ward settings.

Conclusion and implications for practice

the current design of many hospital birth rooms challenges the provision of effective midwifery practice. Changes to the design and aesthetics of the hospital birth room may engender safer, more comfortable and more effective midwifery practice.     

The best of both worlds--parents' motivations for using an alongside birth centre from an ethnographic study

Objective and design

an ethnographic study was undertaken in a birth centre to explore the model of care provided there from the perspectives of midwives and parents.

Setting

a five birthing-room, alongside, inner-city, birth centre in England, situated one floor below the hospital labour ward, separately staffed by purposively recruited midwives.

Participants

around 114 hours were spent at the birth centre observing antenatal, intrapartum and postnatal care; 11 in-depth interviews were recorded with parents after their baby's birth (four with women; seven with women and men together), including three interviews with women who transferred to the labour ward, and 11 with staff (nine midwives and two maternity assistants).

Findings

most women and men using the birth centre perceived it as offering the ‘best of both worlds’ based on its proximity to and separation from the labour ward. It seemed to offer a combination of biopsychosocial safety, made evident by the calm, welcoming atmosphere, the facilities, engaging, respectful care from known midwives and a clear commitment to normal birth, and obstetric safety particularly because of its close proximity to the labour ward.

Key conclusions and implications for practice

this alongside birth centre provided a social model of care and appealed strongly to a group of parents; similar birth centres should be widely available throughout the NHS.     

Birth environment facilitation by midwives assisting in non-hospital births: A qualitative interview study

Objective

midwifery homes (similar to birth centres) are rich in midwifery wisdom and skills that differ from those in hospital obstetrical departments, and a certain percentage of pregnant women prefer birth in these settings. This study aimed to understand the organisation of the perinatal environment considered important by independent midwives in non-hospital settings and to clarify the processes involved.

Design

semi-structured qualitative interview study and constant comparative analysis.

Participants

14 independent midwives assisting at births in midwifery homes in Japan, and six independent midwives assisting at home births.

Setting

Osaka, Kyoto, Nara, and Shiga, Japan.

Findings

midwives assisting at non-hospital births organised the birth environment based on the following four categories: ‘an environment where the mother and family are autonomous’; ‘a physical environment that facilitates birth’; ‘an environment that facilitates the movement of the mother for birth’; and ‘scrupulous safety preparation’. These, along with their sub-categories, are presented in this paper.

Key conclusions

independent midwives considered it important to create a candid relationship between the midwife and the woman/family from the period of pregnancy to facilitate birth in which the woman and her family were autonomous. They also organised a distinctive environment for non-hospital birth, with preparations to guarantee safety. Experiential knowledge and skills played a major part in creating an environment to facilitate birth, and the effectiveness of this needs to be investigated objectively in future research.