Women’s Experiences of Care and Their Concerns and Needs Following a Significant Primary Postpartum Hemorrhage

Abstract: Background: In the context of rising rates of postpartum hemorrhage and little data about its effect on women, this study aimed to describe the experiences of care, and the concerns and needs of women after a significant postpartum hemorrhage. Methods: A cohort of 206 women with a primary postpartum hemorrhage of 1,500 mL or more and/or a peripartum fall in hemoglobin concentration to 7 g/dL or less and/or of 4 g/dL or more was recruited from 17 major hospitals in Australasia. Women rated their satisfaction with care and provided written responses to questions in postpartum questionnaires completed in the first week and at 2 and 4 months postpartum. Results: In relation to care in hospital, consistently over 20 percent women responded that their needs for information, acknowledgment, and reassurance were only met sometimes, rarely, or never. Sixty‐two percent reported that they were given adequate information about their likely physical recovery, and 48 percent about their likely emotional recovery. Four major themes were identified in response to the open‐ended questions: adequacy of care, emotional responses to the experience, implications for the future, and concerns for their baby. Conclusions: This study is an important step in identifying the negative impact of experiencing a significant postpartum hemorrhage during childbirth for women who survive. Our results suggest that health professionals should pay greater attention to these women’s informational and emotional needs. (BIRTH 38:4 December 2011)     

The analysis of negative birth experiences of mothers: a qualitative study

Objective: The aim of this study is to analyse the factors associated with a negative childbirth experience from the perspective of the women who gave birth vaginally.

Background: A negative birth experience can pose a risk for both the maternal/newborn health and the health of the community by disturbing the physical and spiritual health of the woman/family.

Methods: This qualitative study was conducted with 11 mothers who gave birth vaginally assisted by midwives in a state hospital. The data were collected using in-depth interviews and analysed using the thematic analysis technique.

Results: The factors causing the women to have negative birth perceptions were analysed under four main themes: challenges/difficulties encountered, the inadequate communication of health professionals, embarrassment/privacy and inadequate hospital facilities. The mothers indicated that they had experienced their births negatively due to personal reasons such as the inability to cope with labour pain, inability to push, hospital policies such as interventions at birth and hunger. In addition, some of the participants stated that they had difficulty and felt embarrassed during vaginal examinations.

Conclusion: The sociocultural characteristics of mothers, hospital facilities and rules, medical and traditional practices at birth, inadequate empathic communication of health professionals and reproductive health policies can lead to negative childbirth experiences.     

Women's perception of sexuality during pregnancy and after birth

BACKGROUND: Pregnancy and birth mark a distinct period in the life of a woman. Hormonal alterations and bodily and social changes impact on women's physical well-being, mood, relationship and sexuality. Most existing research on sexuality during pregnancy focuses on the quantitative analysis of sexual activities, but neglects subjective experiences of women. AIMS: To examine women's sexual needs, sexual activities, subjective importance of sexuality and contentment with sex life, focusing on the changes over the course of pregnancy and post-partum. METHODS: Twenty-six women completed a series of three extensive interviews in early and late pregnancy, as well as 6 months post-partum. A semiqualitative approach, combining visual analogue scales and a semistructured interview with self-developed questions, was used. RESULTS: The statistical analysis revealed a significant decrease of perceived 'importance of sexuality', 'importance of sexual intercourse' and 'contentment with present sex life', from prepregnancy over early pregnancy to late pregnancy, which was followed by a slight increase in the post-partum period. Samples from the structured interviews provide a detailed insight into female experiences, perceptions and opinions, and demonstrate the high interindividual variability. CONCLUSION: Doctors can provide invaluable advice to women regarding the psychosexual changes and help them to understand the normal fluctuations in sexual interest during pregnancy and the post-partum.     

Pregnancy after periviable birth: making the case for innovative delivery of interpregnancy care*

Objective: Women who have had a spontaneous periviable delivery are at high risk for recurrent preterm delivery. The objective of our study was to determine interpregnancy interval (IPI) after periviable birth as well as percentage of women taking 17 alpha hydroxyprogesteronecaproate (17OHP-C) after periviable birth. We then examined the association between adherence with a postpartum visit after a periviable birth and IPI as well as receipt of 17OHP-C.

Materials and methods: We included all women with a periviable delivery (20–26-week gestation) due to spontaneous preterm birth at Magee Women’s Hospital between 2009 and 2014, who had their subsequent delivery at our institution during or before May of 2016. Information on maternal, fetal, and neonatal outcomes was obtained from the Magee Obstetrical Medical and Infant (MOMI) database as well as chart abstraction. We calculated IPI, proportion of women who received 17OHP-C in their next pregnancy, and attendance rates with a postpartum visit. The relationship between attendance with a postpartum visit and IPI, and receipt of 17OHP-C was examined with a logistic regression.

Results: During the study period, 361 women had a spontaneous periviable birth. A total of 60 women had a subsequent delivery at Magee Women’s Hospital. Only 33/60 (52.5%) presented for a postpartum visit after their periviable delivery. The median IPI for the cohort was 12.5 months (interquartile range: 6.4, 17.5 months) and 21.0% (n?=?13) had an IPI less than 6 months. Adherence with the postpartum visit was not associated with an IPI less than 6 months. A total of 18.33% (11 women) did not receive 17OHP-C in their subsequent pregnancy. Women who attended a postpartum visit were much more likely to receive 17OHP-C (p?=?.001).

Conclusions: Many women with a history of a periviable birth do not optimize strategies to reduce their risk of recurrent preterm birth. While attendance with a postpartum visit was associated with greater receipt of 17OHP-C in the subsequent pregnancy, given the overall poor rate of attendance with the postpartum visit in this cohort, novel strategies to counsel women about interpregnancy health are needed.     

Rate of preterm birth in pregnant women with vitamin E treatment: a population-based study

Objective: Vitamin E is frequently used for prevention/treatment of repeated or threatened abortion and threatened preterm delivery in Hungarian pregnant women, though, internationally this old-fashion method is not recommended. Methods: The rate of preterm birth of newborns in pregnant women with high dose (estimated daily dose 450?mg) vitamin E treatment or without this treatment was compared in the population-based large data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities. Results: Of 38,151 newborns with any defect, 2,287 (6.0%) had mothers with vitamin E treatment. Pregnant women with vitamin E treatment had very high rate of threatened abortion (43.6% vs. 15.4%) and high rate of threatened preterm delivery (27.5% vs. 13.4%) compared to pregnant women without vitamin E treatment. Nevertheless, the gestational age at delivery was 0.2 week longer and rate of preterm births was lower in the newborns of pregnant women with vitamin E treatment (6.6% vs. 9.3%; adjusted OR with 95% CI: 0.71, 0.63–0.84). This preterm preventive effect of vitamin E treatment could not be explained by known confounders, though folic acid/multivitamins also reduced the rate of preterm birth. Conclusion: The study showed nearly 30% reduction in preterm births of pregnant women with vitamin E treatment.     

Healthcare professionals' views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section: a qualitative study

Objective  To explore healthcare professionals' views about decision aids, developed by the DiAMOND study group, for women choosing mode of delivery after a previous caesarean section.
Design/Methods  A qualitative focus group study. Data were analysed thematically.
Setting  Two city maternity units, surrounding community midwife units and general practitioner (GP) practices in southwest England.
Sample  Twenty-eight healthcare professionals, comprising obstetricians, hospital and community midwives and GPs, who participated in six focus groups.
Results  Participants were generally positive about the decision aids. Most thought they should be implemented during early pregnancy in the community, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. Perceived barriers to implementation included service issues (e.g. time pressure, cost and access), computer issues (e.g. computer literacy) and people issues (e.g. women's prior delivery preferences and clinician preference). Facilitators to implementation included access to more standardised and reliable information and empowerment of the user. Self-accessing the aids, increased awareness of decision aids among healthcare professionals and incorporation of aids into usual care were suggested as possible ways to improve implementation success.
Conclusions  This study gives insight into healthcare professionals' views on the role of decision aids for women choosing a mode of delivery after a prior caesarean section. It highlights potential obstacles to their implementation and ways to address these. Such aids could be a useful adjunct to current antenatal care.     

Applying the global positioning system and google earth to evaluate the accessibility of birth services for pregnant women in northern Malawi

Introduction: The objective of this study was to validate the combined use of the Global Positioning System (GPS) and Google Earth for measuring the accessibility of health care facilities for pregnant women in northern Malawi. Methods: We used GPS and Google Earth to identify 5 major health care facilities in Mzuzu (Malawi) and the homes of 79 traditional birth attendants (TBAs). The distance and time required for each TBA to reach the nearest health care facility were measured by both GPS and by self‐report of the TBAs. A convenience sample of 1138 pregnant women was interviewed about their choices of birth sites for current and previous pregnancies and the time and cost required to access health care facilities. Results: The correlation coefficient between the objective measurements by GPS and subjective reports by TBAs for time required from their homes to health care facilities was 0.654 (P < .001). Among pregnant women, 45.6% reported that they could reach a health care facility within 2 hours; 23.8% reported paying more than $1 for transportation to health care facilities. For the current study, 82.6% of women intended to give birth at a health care facility. However, only 48.7% of women actually gave birth in a health care facility in a previous pregnancy, and 32.6% were assisted by TBAs. Discussion: Combined GPS and Google Earth can be useful in the evaluation of accessibility of health care facilities, especially for emergency obstetric care.     

Spontaneous preterm birth of liveborn infants in women at low risk in Australia over 10 years: a population-based study

Objectives  To describe a 10-year trend in preterm birth.
Design  Population-based study.
Setting  Australia.
Population  All women who gave birth during 1994–03.
Methods  The proportion of spontaneous preterm births (greater than or equal to 22 weeks of gestation and less than 37 completed weeks of gestation) was calculated by dividing the number of women who had a live spontaneous preterm birth (excluding elective caesarean section and induction of labour) by the total number of women who had a live birth after spontaneous onset of labour (excluding elective caesarean section and induction of labour). This method was repeated for the selected population of women at low risk.
Main outcome measure  Preterm birth rates among the overall population of women; preterm birth among all women with a spontaneous onset of labour; and preterm birth in a selected population of women who were either primiparous or multiparous, non-Indigenous; aged 20–40 years and who gave birth to a live singleton baby after the spontaneous onset of labour.
Results  Over the 10-year study period, the proportion of all women having a live preterm birth in Australia increased by 12.1% (from 5.9% in 1994 to 6.6% in 2003). Among women with a spontaneous onset of labour, there was an increase of 18.3% (from 5.7 to 6.7%). Among the selected population of low-risk women after the spontaneous onset of labour, the rate increased by 10.7% (from 5.6 to 6.2%) among first time mothers and by 19.2% (4.4–5.2%) among selected multiparous women.
Conclusions  Over the 10-year period of 1994–03, the rate of spontaneous preterm birth among low-risk women having a live singleton birth has risen in Australia.     

Afro-Surinamese women in the Netherlands: Sexual education,the initiation of sex,and contraceptive use

Surinamese women in Holland have a higher fertility rate and a much higher abortion rate than Dutch women in general. A sample of 60 Surinamese women throughout Holland were interviewed about their experience of sexual education, their initial sexual experiences, their use of contraception and pregnancies. Factors in their sexual career associated with a heightened risk of an unplanned pregnancy are recorded.     

Vaginal birth after Caesarean versus elective repeat Caesarean for women with a single prior Caesarean birth: a systematic review of the literature

AIMS: To assess the benefits and harms of planned elective repeat Caesarean section with planned vaginal birth after Caesarean section (VBAC). METHODS: The Cochrane controlled trials register and MEDLINE (1966-current) were searched using the following terms: vaginal birth after C(a)esare(i)an; trial of labo(u)r; elective C(a)esare(i)an; C(a)esare(i)an section, repeat; randomis(z)ed controlled trial; randomis(z)ed trial; clinical trial; and prospective cohort study, to identify all published randomised controlled trials and prospective cohort studies. Primary outcomes related to success of trial of labour, need for Caesarean section, maternal and neonatal mortality, and morbidity. RESULTS: There were no randomised controlled trials identified that compared planned elective repeat Caesarean birth with planned vaginal birth. Two prospective cohort studies were identified where all 449 women compared had a single prior Caesarean section in their immediately preceding pregnancy and were suitable for an attempted VBAC in their next pregnancy. For all outcomes, data were available from a single study only. Reported outcome data were available for maternal deaths (0/137 women), in utero fetal deaths (2/312 fetuses), neonatal deaths (0/137 infants), uterine scar dehiscence (2/137 women), uterine scar rupture (1/312 women), and infant Apgar score of less than seven at 5 min of age (9/312 infants). There were no statistically significant differences between planned elective repeat Caesarean section and planned VBAC. CONCLUSIONS: There is a paucity of quality information available to assist women and their caregivers regarding optimal mode of birth for women with a single prior Caesarean section in their next pregnancy.     

A multisite audit to assess how women with complex social factors access and engage with maternity services

Objectiveto audit women with socially complex lives’ documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.Backgroundwomen living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.Methoddata was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.Findingsnon-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.Conclusionthis data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.