Possibilities for dialogue on sexuality and sexual abuse—midwives’ and clinicians’ experiences

Objective

to describe midwives’ and clinicians’ experiences of the possibilities and obstacles for dialogue with young women on sexuality and sexual abuse, focusing on the possibilities.

Design

qualitative study with interview data analysed by qualitative content analysis.

Setting

South-west Sweden.

Participants

a purposive sample, consisting of 15 midwives, six gynaecologists and five general practitioners aged 30-65 years, was chosen in order to obtain as many different experiences as possible. The participants’ professional experiences varied, ranging from five to more than 35 years, and they were employed at youth clinics, primary health-care centres, gynaecology clinics, a specialist sexual medicine centre and antenatal care centres, situated in small and large cities.

Findings

the participants described the respectful encounter that can be created when young women meet midwives and clinicians in the context of a gynaecological consultation. In this situation, there was a potential to strengthen women while attempting to improve their sexual health. Support from the organisation and the use of personal skills and assets were found to be promoting factors for dialogue. Lack of organisational support or communication skills and difficult emotions complicated the situation, which might, in turn, restrain midwives and clinicians from raising sexual issues.

Implications for practice

increased knowledge, support and opportunities for reflection concerning dialogue regarding sexual issues might evoke the interest and intent of health professionals to approach these issues. Guidelines regarding dialogue about both sexuality and sexual abuse should be routine in health-care services.     

Factors associated with inadequate prenatal care in Ecuadorian women

Background

Although inadequate prenatal care has been associated with adverse perinatal outcomes, reports on the factors associated with poor prenatal care in developing Latin American countries are scarce.

Objective

To determine factors associated with inadequate prenatal care among women from low socioeconomic circumstances.

Method

Women delivered after a pregnancy duration of more than 20 weeks at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, were surveyed. The questionnaire collected sociodemographic data and reasons for having inadequate prenatal care. Adequacy of prenatal care was measured with the Kessner index and correlated to the sociodemographic data.

Results

During the study period, 1016 pregnant women were surveyed. Among them, there were adolescents (23.7%), primigravidas (30.8%), and women with a high-risk pregnancy (29.3%). According to the Kessner index, prenatal care was considered adequate or inadequate in 24.5% and 75.5% of cases, respectively. Knowledge regarding the importance of adequate prenatal care and the effects of poor prenatal care was lower among women who had received inadequate prenatal care. The women that were considered to have had adequate prenatal care had at least one visit, and they were more often cared for by a specialist than women who considered having inadequate prenatal care. The three most important reasons associated to inadequate prenatal care in this series (n=767), were economic difficulties having to care for a small child, and transportation difficulties. Logistic regression analysis determined that women with undesired pregnancies who resided in rural areas and were para 5 or higher had an increased risk of inadequate prenatal care. On the other hand, an adverse outcome to a prior pregnancy (abortion, intrauterine fetal demise, or ectopic pregnancy) decreased this risk. Marital status and educational level were confounding factors.

Conclusions

Although prenatal care at our institution is free, adequacy was thought to be low. The main factors associated with poor prenatal care were mostly conditions related to poverty.     

Chilean midwives and midwifery students’ views of women’s midlife health-care needs

Objective

to determine Chilean midwives’ views with regard to Chilean women’s health-care needs in midlife. The aim was also to explore Chilean midwifery students’ views on the clinical care provided to women in midlife.

Design

a qualitative study using focus group discussions and narratives which were analysed using thematic manifest and latent content analysis.

Setting

10 different primary health care (PHC) centres in Santiago, Chile.

Participants

22 midwives, working in PHC clinics and 13 (n=13) midwifery students with PHC clinical experience, attending their fourth or fifth year of midwifery education at the School of Midwifery in Santiago.

Findings

the midwives felt that women in midlife have special health-care service needs. They also considered themselves to be the most appropriate health staff to provide health care for women in midlife, but recognised that they lacked competence in attending psychological and social health-care needs of women in midlife such as violence, abuse and sexuality issues. The midwifery students remarked that many midwives focused their attention on fulfilling the biomedical requirements. Even if the midwives had knowledge about recent research on menopause, they had difficulties in approaching this issue and including it in their counselling. Some students also questioned the sometimes disrespectful attitude shown, especially towards Peruvian immigrants and women with psychosocial problems.

Conclusions and implications for practice

the findings suggest that midwives need more education about women’s health-care needs in midlife, and that more focus should be placed on the psychosocial aspects of midwifery. More reflections about the quality of the client-provider relationship in clinical practice are needed. Gender issues, the structure of power relationships, and empowerment should be incorporated and critically discussed during midwifery education and training, and also in clinics.     

Uterine massage to reduce postpartum hemorrhage after vaginal delivery

Objective

To determine the effectiveness of sustained uterine massage started before delivery of the placenta in reducing postpartum hemorrhage.

Methods

A randomized controlled trial conducted in Egypt and South Africa between September 2006 and February 2009. A total of 1964 pregnant women were randomly allocated to 1 of 3 treatment groups: intramuscular oxytocin, sustained uterine massage, or both treatments. Blood loss within 30 minutes of delivery was recorded.

Results

The incidence of blood loss of 300 mL or more within 30 minutes of delivery was significantly higher in the massage group than in the massage plus oxytocin (RR 1.88; 95% CI, 1.29-2.74 in Assiut, and RR 1.3; 95% CI, 1.00-1.68 in SA) and the oxytocin only group (RR 1.7; 95% CI, 1.11-2.61 in Assiut, and RR 2.24; 95% CI, 1.54-3.27 in SA). In both centers, use of additional uterotonics was significantly higher in the uterine massage group compared with the other 2 groups.

Conclusion

Uterine massage was less effective than oxytocin for reducing blood loss after delivery. When oxytocin was used, there was no additional benefit from uterine massage. The effectiveness of uterine massage in the absence of oxytocin was not studied. ACTRN: 12609000372280.     

Association of intimate partner physical and sexual violence with unintended pregnancy among pregnant women in Peru

Objective

To examine the associations between lifetime physical and/or sexual intimate partner violence (IPV) with pregnancy intent among pregnant women in Lima, Peru.

Methods

A total of 2167 women who delivered at the Instituto Nacional Materno Perinatal, Lima, Peru were interviewed during the postpartum recovery period. Logistic regression was used to estimate multivariable adjusted odds ratios and 95% confidence intervals.

Results

Lifetime physical or sexual violence (40.0%) and unintended pregnancies (65.3%) were common in the study population. Compared with non-abused women, abused women had a 1.63-fold increased risk for unintended pregnancy. Unintended pregnancy risk was 3.31-fold higher among women who experienced both physical and sexual abuse compared with non-abused women. The prevalence and severity of physical violence during pregnancy was greater among women with unintended pregnancies compared with women with planned pregnancies.

Conclusion

The findings indicate the need to include IPV screening and treatment in prenatal care and reproductive health settings.     

Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care

Objective

To characterize prenatal and delivery care in an urban African setting.

Methods

The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector.

Results

From June 1, 2007, to January 31, 2010, 115 552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23 weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95 663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111 108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112 813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38 weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000 g (IQR 2700-3300 g).

Conclusion

The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.     

Routinisation and constraints on informed choice in a one-stop clinic offering first trimester chromosomal antenatal screening for Down's syndrome

Objective

to explore routinisation and constraints on informed choice in a one-stop clinic offering first trimester antenatal chromosomal screening for Down’s syndrome.

Design

recordings of booking appointments and pre-screening consultations in both a community and a hospital clinic setting.

Setting

one antenatal clinic site in the UK offering first trimester nuchal translucency screening in combination with maternal serum screening.

Participants

57 taped clinical consultations involving pregnant women and midwives and health-care assistants (HCAs).

Findings

midwives and HCAs expected women to make informed decisions about screening for Down’s syndrome. However, midwives’ attempts to maintain the normality of pregnancy and avoid discussions about potential scenarios, as well as their emphasis on the high accuracy rate of first trimester screening have routinised first trimester antenatal screening for Down’s syndrome. Also, a general expectation in the clinic to take up screening and the constrained service context in which midwives and HCAs work had implications for women’s informed choices.

Key conclusions

directive information combined with lack of purposeful dialogue with pregnant women have constrained the process of information-giving about antenatal screening for Down’s syndrome.

Implications

the provision of information about antenatal screening for Down’s syndrome is a challenging role for midwives. Changes in midwifery practice resulting from continuing education as well as less constraining service contexts could improve the quality of information about antenatal screening for Down’s syndrome.     

Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India

Objective

To determine the cost-effectiveness of prenatal iron supplementation and misoprostol use as interventions to prevent maternal mortality in home births in rural India.

Methods

A cost-effectiveness analysis depicted three hypothetical cohorts of 10 000 pregnant women delivering at home in rural India: one with no intervention, one receiving standard prenatal iron supplements, and 1 receiving 600 µg of misoprostol in the third stage of labor.

Results

Misoprostol used to prevent postpartum hemorrhage resulted in a 38% (95% CI, 5%-73%) decrease in maternal deaths, while prenatal iron supplementation resulted in a 5% (95% CI, 0%-47%) decrease. Misoprostol cost a median US $1401 (IQR US $1008-$1848) prenatal iron supplementation cost a median US $2241 (IQR No Lives Saved-$3882) per life saved compared with the standard care outcome.

Conclusion

Misoprostol is a cost-effective maternal mortality intervention for home births. Iron supplementation may be worthwhile to improve women's health, but it is uncertain whether it can prevent mortality after hemorrhage.     

Effect of prenatal and perinatal antibiotics on maternal health in Malawi, Tanzania, and Zambia

Objective

We assessed the effect of prenatal and peripartum antibiotics on maternal morbidity and mortality among HIV-infected and uninfected women.

Methods

A multicenter trial was conducted at clinical sites in 4 Sub-Saharan African cities: Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. A total of 1558 HIV-infected and 271 uninfected pregnant women who were eligible to receive both the prenatal and peripartum antibiotic/placebo regimens were enrolled. Pregnant women were interviewed at 20-24 weeks of gestation and a physical examination was performed. Women were randomized to receive either antibiotics or placebo. At the 26-30 week visit, participants were given antibiotics or placebo to be taken every 4 hours beginning at the onset of labor and continuing after delivery 3 times a day until a 1-week course was completed. Logistic regression and Cox proportional hazards models were used.

Results

There were no significant differences between the antibiotic and placebo groups for medical conditions, obstetric complications, physical examination findings, puerperal sepsis, and death in either the HIV-infected or the uninfected cohort.

Conclusion

Administration of study antibiotics during pregnancy had no effect on maternal morbidity and mortality among HIV-infected and uninfected pregnant women.     

Maternity services in multi-cultural Britain: using Q methodology to explore the views of first- and second-generation women of Pakistani origin

Objective

to explore first- and second-generation Pakistani women’s experiences of maternity services and the inter generational differences/comparisons.

Design

a retrospective Q methodology study of Pakistani women following childbirth.

Setting

two Children's Centres in an inner city in the West Midlands.

Participants

women self-identified following distribution of information leaflets at Children’s Centres. Fifteen women took part in interviews (Stage one) using a semi-structured design and 16 women participated in the completion of the Q grid sorting (Stage four).

Methods

a standard five-stage Q methodology process took place: (1) initial data were gathered using a combination of individual face-to-face and focus group semi-structured community-based interviews (developing the concourse); (2) transcribed interviews were analysed for ‘themes’; (3) the themes were reduced to ‘statements’ that reflected the overall content of the concourse using an unstructured evolving approach (giving the Q set); (4) participants were asked to sort the statements (Q sorting) according to a pre-designed distribution grid providing individual participant response grids; and (5) the response grids were factor analysed using PQ Method (V2.11), which generates clusters of participants rather than clusters of variables. Factor loadings were calculated using factor analysis by principal components with varimax rotation. This produced a list of factors, each of which represents a ‘story’ of women’s experiences of maternity services. Throughout the process, an Urdu interpreter was involved.

Findings

six factors were identified: (1) confidence and empowerment of women who had attended higher education and had family support; (2) isolation of some women from both family and maternity services; (3) women who had poor experiences of maternity services but good family support, and wanted opportunities to be involved in service development; (4) women with positive experiences of maternity care and influenced by traditional cultural practices; (5) importance of information and support from health-care professionals; and (6) importance of midwifery care to women.

Conclusion

there were no clear inter generational differences identified, but a breadth of opinion and experience that seemed to be influenced by level of both education and social support was found. Whereas some women had few demands of maternity services, those who had less support and those with language barriers had additional needs.

Implications for practice

care given should be based on individual need but given within a wider collaborative context in order to support women effectively. Increased maternity service user involvement would also be welcomed for future planning of maternity services.     

Outcomes of pregnancies affected by hemoglobin H disease

Objective

To determine the outcomes of pregnancies affected by hemoglobin H (HbH) disease.

Methods

A retrospective cohort study was conducted with 120 women with singleton pregnancies complicated by HbH disease only. The controls-to-cases ratio was 2:1.

Results

Maternal outcomes were similar in the 2 groups. The incidences of fetal growth restriction (relative risk [RR], 2.4; 95% confidence interval [CI], 1.60-3.50), preterm birth (RR, 1.4; 95% CI, 1.03-1.96), and low birth weight (RR, 1.9; 95% CI, 1.46-2.56) were significantly higher in the study than in the control group. The perinatal mortality rate was slightly higher in the study group.

Conclusion

In spite of attempts to keep hemoglobin levels sufficiently high (> 7.0 g/dL), pregnancies with HbH disease were significantly associated with increased risks of fetal growth restriction, preterm birth, and low birth weight.     

Inequalities in cesarean delivery rates by ethnicity and hospital accessibility in Brazil

Objective

To investigate inequalities in cesarean delivery rates in Brazil according to ethnic group and level of access to hospital delivery.

Methods

Cross-sectional analysis of data for primiparous women with singleton deliveries between 2003 and 2004 from the National Information System of Live-Births (6 064 799 live births). Robust Poisson regression modeling was applied to estimate prevalence ratios of cesarean deliveries for ethnic group and level of access to hospital delivery according to residence.

Results

There were 2 438 180 primiparous deliveries and the cesarean rate was 45.8%. Ethnic inequalities in cesarean delivery rates showed lower rates for all ethnic groups compared with white women, with the lowest rates recorded for indigenous women. The association between ethnicity and cesarean delivery was higher in states with lower access to hospital (P < 0.001). Multiple regression models showed that this association was, in part, explained by older maternal age and higher levels of education and prenatal care.

Conclusions

Overuse of cesarean delivery and strong evidence of ethnic inequalities in cesarean rates exist in Brazil. The inequalities are greater in states with lower access to hospital and were partially explained by socioeconomic factors and prenatal care, suggesting a misuse of medical technology at birth.     

Health service utilisation by pregnant women over a seven-year period

Objective

to examine the use of complementary and alternative medicine during pregnancy using data from a longitudinal cohort study.

Design and setting

the research was conducted as part of the Australian Longitudinal Study on Women’s Health which was designed to investigate multiple factors affecting the health and well-being of women over a 20-year period.

Participants

the younger cohort of the Australian Longitudinal Study on Women’s Health who had completed four surveys in 1996, 2000, 2003 and 2006.

Findings

the data reveal an increase both in consumption of complementary and alternative medicine and in consultations with general practitioners/specialists during pregnancy. Women utilised complementary and alternative medicine as a supplement for conventional maternity care.

Implications for practice

given the potential risks of some complementary and alternative medicine for pregnant women and their unborn child, it is essential that maternity care providers are adequately informed about these treatments and that further research investigates the details of such concurrent use.     

Kurdish pregnant women's feelings: A qualitative study

Objective

to gain a deeper understanding of how Kurdish pregnant women feel about their pregnancy.

Design

a qualitative study analysed by a grounded theory approach.

Setting

the study was conducted among women in the third trimester of their pregnancy in either their homes or the health-care centres in Sanandaj in the western part of Iran.

Participants

22 pregnant women were recruited and interviewed.

Findings

during pregnancy, women experienced a variety of feelings: ‘satisfied and happy’, ‘unpleasant’ and ‘ambivalent’.

Conclusions and implications for practice

it is important for midwives to ask pregnant women about their feelings concerning their current pregnancy, childbirth and future motherhood. If they express negative or ambivalent feelings, these should be discussed in greater detail and their causes identified. Special consideration should be given to primiparous women and multiparous women with negative experiences of previous pregnancies.     

Ethnic differences in antenatal care use in a large multi-ethnic urban population in the Netherlands

Objective

to determine differences in antenatal care use between the native population and different ethnic minority groups in the Netherlands.

Design

the Generation R Study is a multi-ethnic population-based prospective cohort study.

Setting

seven midwife practices participating in the Generation R Study conducted in the city of Rotterdam.

Participants

in total 2093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese-Creole and Surinamese-Hindustani background were included in this study.

Measurements

to assess adequate antenatal care use, we constructed an index, including two indicators; gestational age at first visit and total number of antenatal care visits.Logistic regression analysis was used to assess differences in adequate antenatal care use between different ethnic groups and a Dutch reference group, taking into account differences in maternal age, gravidity and parity.

Findings

overall, the percentages of women making adequate use are higher in nulliparae than in multiparae, except in Dutch women where no differences are present.Except for the Surinamese-Hindustani, all women from ethnic minority groups make less adequate use as compared to the native Dutch women, especially because of late entry in antenatal care. When taking into account potential explanatory factors such as maternal age, gravidity and parity, differences remain significant, except for Cape-Verdian women. Dutch-Antillean, Moroccan and Surinamese-Creole women exhibit most inadequate use of antenatal care.

Key conclusions

this study shows that there are ethnic differences in the frequency of adequate use of antenatal care, which cannot be attributed to differences in maternal age, gravidity and parity. Future research is necessary to investigate whether these differences can be explained by socio-economic and cultural factors.

Implications for practise

clinicians should inform primiparous women, and especially those from ethnic minority groups, on the importance of timely antenatal care entry.     

Knowledge about HIV infection and acceptability of HIV testing among women delivered in Podkarpackie Province, Poland

Objective

To assess the knowledge of pregnant Polish women regarding the risk of perinatal HIV transmission, the ways to reduce this risk, and the importance of HIV testing in pregnancy, as well as their willingness to be tested for HIV.

Methods

A multicenter survey was conducted with 2123 pregnant women from Podkarpackie Province using a 4-part questionnaire.

Results

Only 15.4% of the women, mainly those with higher education, correctly assessed the risk of perinatal HIV transmission; 61.9% showed adequate knowledge of perinatal HIV transmission, mainly older, well-educated, multiparas residing in towns; and 81.1% declared a willingness to undergo HIV testing, mainly well-educated primigravidas in the 26 to 30 years age group residing in towns.

Conclusion

These pregnant women from Poland, where prenatal HIV testing is rarely done, showed a limited knowledge of perinatal HIV transmission but a high willingness to undergo HIV testing.