Chinese midwives' views on a proposed midwife-led normal birth unit

Objective

to investigate and assess Chinese midwives’ views of their roles and ability to practice in a proposed midwife-led normal birth unit (MNBU).

Design

a self-completed questionnaire supplemented with semi-structured telephone interviews. Memos, diaries, correspondence and comments of Chinese collaborators were also accessed.

Setting

six hospitals in Hangzhou, the capital of Zhejiang province.

Participants

143 midwives were contacted and completed the questionnaire survey. Three midwives were subsequently interviewed.

Findings

the response rate was 100%; 86% of midwives supported the development of an MNBU, and 94.4% expressed confidence that they would be able to practice in an MNBU. The study shed new light on: (1) the meaning of an MNBU in the Chinese context; (2) the need for development of an MNBU; (3) role conflicts among midwives, doulas, nurses and obstetricians; (4) professional expertise and tension; and (5) the low status of Chinese midwives.

Conclusion

the proposed MNBU is welcomed by Chinese midwives. Their consensus and confidence show that there is enthusiasm for this project to proceed. However, the Chinese have never thought of MNBU services before. There is a need to develop well-structured philosophy, policy, procedures and outcome measures.

Implications for practice

the findings highlight the importance of an MNBU to re-establish Chinese midwives’ support of physiological childbirth. The extent to which Chinese midwives understand an MNBU could be further explored. The result may provide a possible route to the continuity of midwifery care and support.     

Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study

Aims

to report the clinical outcomes of the first six months of operation of an innovative midwife-led normal birth unit (MNBU) in China in 2008, aiming to facilitate normal birth and enhance midwifery practice.

Setting

an urban hospital with 2000–3000 deliveries per year.

Method

this study was part of a major action research project that led to implementation of the MNBU. A retrospective cohort and a questionnaire survey were used. The data were analysed thematically.

Participants

the outcomes of the first 226 women accessing the MNBU were compared with a matched retrospective cohort of 226 women accessing standard care. In total, 128 participants completed a satisfaction questionnaire before discharge.

Main outcome measure

mode of birth and model of care.

Findings

the vaginal birth rate was 87.6% in the MNBU compared with 58.8% in the standard care unit. All women who accessed the MNBU were supported by both a midwife and a birth companion, referred to as ‘two-to-one’ care. None of the women labouring in the standard care unit were identified as having a birth companion.

Discussion

the concept of ‘two-to-one’ care emerged as fundamental to women’s experiences and utilisation of midwives’ skills to promote normal birth and decrease the likelihood of a caesarean section.

Conclusion

the MNBU provides an environment where midwives can practice to the full extent of their role. The high vaginal birth rate in the MNBU indicates the potential of this model of care to reduce obstetric intervention and increase women’s satisfaction with care within a context of extraordinary high caesarean section rates.

Implications for practice

midwife-led care implies a separation of obstetric care from maternity care, which has been advocated in many European countries.     

Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective

Objective

to explore midwives’ experiences of facilitating normal birth in an obstetric-led unit.

Design

a feminist approach using semi-structured interviews focusing on midwives’ perceptions of normal birth and their ability to facilitate this birth option in an obstetric-led unit.

Setting

Ireland.

Participation

a purposeful sample of 10 midwives with 6–30 years of midwifery experience. All participants had worked for a minimum of 6 years in a labour ward setting, and had been in their current setting for the previous 2 years.

Findings

the midwives’ narratives related to the following four concepts of patriarchy: ‘hierarchical thinking’, ‘power and prestige’, ‘a logic of domination’ and ‘either/or thinking’ (dualisms). Two themes, ‘hierarchical thinking’ and ‘either/or thinking’, (dualisms) along with their subthemes are presented in this paper.

Key conclusions and implications for practice

this study identified some of the reasons why midwives find it difficult to facilitate normal birth in an obstetric unit setting, and identified a need for further research in this area. Midwifery education and supportive management structures are required if midwives are to become confident practitioners of normal birth.     

Preferred place of birth: Characteristics and motives of low-risk nulliparous women in the Netherlands

Objective

to explores preferences, characteristics and motives regarding place of birth of low-risk nulliparous women in the Netherlands.

Design

a prospective cohort study of low-risk nulliparous women and their partners starting their pregnancy in midwifery-led care or in obstetric-led care. Data were collected using a self-administered questionnaire, including questions on demographic, psychosocial and pregnancy factors and statements about motives with regard to place of birth. Depression, worry and self-esteem were explored using the Edinburgh Depression Scale (EDS), the Cambridge Worry Scale (CWS) and the Rosenberg Self Esteem Scale (RSE).

Setting

participants were recruited in 100 independent midwifery practices and 14 hospitals from 2007 to 2011.

Participants

550 low-risk nulliparous women; 231 women preferred a home birth, 170 women a hospital birth in midwifery-led care and 149 women a birth in obstetric-led care.

Findings

Significant differences in characteristics were found in the group who preferred a birth in obstetric-led care compared to the two groups who preferred midwifery-led care. Those women were older (F (2,551)=16.14, p<0.001), had a higher family income (χ² (6)=18.87, p=0.004), were more frequently pregnant after assisted reproduction (χ²(2)=35.90, p<0.001) and had a higher rate of previous miscarriage (χ²(2)=25.96, p<0.001). They also differed significantly on a few emotional aspects: more women in obstetric-led care had symptoms of a major depressive disorder (χ²(2)=6.54, p=0.038) and were worried about health issues (F (2,410)=8.90, p<0.001). Women's choice for a home birth is driven by a desire for greater personal autonomy, whereas women's choice for a hospital birth is driven by a desire to feel safe and control risks.

Key conclusions

the characteristics of women who prefer a hospital birth are different than the characteristics of women who prefer a home birth. It appears that for women preferring a hospital birth, the assumed safety of the hospital is more important than type of care provider. This brings up the question whether women are fully aware of the possibilities of maternity care services. Women might need concrete information about the availability and the characteristics of the services within the maternity care system and the risks and benefits associated with either setting, in order to make an informed choice where to give birth.     

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.     

Cost-effectiveness analysis of the surgical treatment of female urinary incontinence using slings and meshes

Objective

To determine the cost-utility and cost-effectiveness of the surgical treatment of female urinary incontinence using suburethral slings and prolapse meshes compared with therapeutic abstention.

Study design

An economic analysis was performed on 69 women receiving surgical treatment for urinary incontinence using suburethral slings and prolapse meshes. To calculate the procedure's cost-effectiveness, an incremental analysis up to one year was performed using the incremental cost-effectiveness ratio (ICER). The costs were calculated using a cost-by-process model. Answers to the health-related quality of life questionnaires EQ-5D (generic) and International Consultation Incontinence Questionnaire Short-form (specific) were collected before the operation and as well as one month and one year post-operation to calculate the utility, using quality-adjusted life years (QALY), and the effectiveness, respectively. To complete the economic evaluation, we derived confidence ellipses and acceptability curves. The analysis was conducted for the entire sample and also for each type of urinary incontinence.

Results

In total, 45 women presented with stress incontinence, 15 with mixed incontinence and 9 with incontinence associated with prolapse. The average cost per patient at one year post-operation was 1220 €. The QALY achieved at one year was 0.046. The results reveal an ICER at one year of 26,288 €/QALY, which is below the cost-effectiveness threshold considered acceptable, and this value was lower for stress incontinence (21,191 €/QALY). The cost-effectiveness was 106.5 €/International Consultation Incontinence Questionnaire Short-form unit.

Conclusion

Surgery for female urinary incontinence using slings is cost-effective compared with abstention in our public health environment.     

Water VBAC: Exploring a new frontier for women's autonomy

Background

although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted. Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes.

Method

in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit. The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted.

Findings

the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences. The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section. Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women's childbirth experience. This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences. Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth. The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care.

Conclusions

for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process. The value accorded to being able to exercise choice and control over their childbearing experience was high. These women's accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.     

Factors influencing women's decision to have a home birth in rural Turkey

Objective

to ascertain the reasons why mothers choose to have a home birth and the factors that influence these reasons.

Methods

this cross-sectional study involved 392 women and was conducted between June and September 2003 in a rural setting in Turkey. The data were collected using a questionnaire developed by the authors. The questionnaire included demographic information, obstetric background, the reasons for deciding to give birth at home as well as questions on who encouraged the decision to give birth at home and who assisted in the home births.

Findings

the decision to have a home birth is related to economic difficulties and the desire to benefit from the assistance of neighbours. Women who had experienced both planned and unplanned home births reported that home birth was unsafe.

Conclusion

preliminary information is provided about women having home births that may inform practitioners’ educational efforts and future research.     

Determinants of place of birth decisions in uncomplicated childbirth in Bangladesh: An empirical study

Objective

to test the predictive value of women's self-identified criteria in place of birth decisions in the event of uncomplicated childbirth in a setting where facility based skilled birth attendants are available.

Design

a retrospective, cross-sectional study was conducted in two phases. The first phase used data from in-depth interviews. The second phase used data from semi-structured questionnaires.

Setting

the service area of Matlab, Bangladesh.

Participants

women 18–49 years who had an uncomplicated pregnancy and delivery resulting in a live birth.

Findings

a women's intention about where to deliver during pregnancy, her perception of labour progress, the availability of transportation at the time of labour, and the close proximity of a dai to the household were independent predictors of facility-based SBA use. Marital age was also significant predictor of use.

Key conclusions

the availability of delivery services does not guarantee use and instead specific considerations and conditions during pregnancy and in and around the time of birth influence the preventive health seeking behaviour of women during childbirth. Our findings have implications for birth preparedness and complication readiness initiatives that aim to strengthen timely use of SBAs for all births. Demand side strategies to reduce barriers to health seeking, as part of an overall health system strengthening approach, are needed to meet the Millennium Development 5 goal.     

Empowering change: Realist evaluation of a Scottish Government programme to support normal birth

Background

midwife-led care has consistently been found to be safe and effective in reducing routine childbirth interventions and improving women's experience of care. Despite consistent UK policy support for maximising the role of the midwife as the lead care provider for women with healthy pregnancies, implementation has been inconsistent and the persistent use of routine interventions in labour has given rise to concern. In response the Scottish Government initiated Keeping Childbirth Natural and Dynamic (KCND), a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.

Aim

the evaluation was informed by realist evaluation. It aimed to explore and explain the ways in which the KCND programme worked or did not work in different maternity care contexts.

Methods

the evaluation was conducted in three phases. In phase one semi-structured interviews and focus groups were conducted with key informants to elicit the programme theory. At phase two, this theory was tested using a multiple case study approach. Semi-structured interviews and focus groups were conducted and a case record audit was undertaken. In the final phase the programme theory was refined through analyses and interpretation of the data.

Setting and participants

the setting for the evaluation was NHS Scotland. In phase one, 12 national programme stakeholders and 13 consultant midwives participated. In phase two case studies were undertaken in three health boards; overall 73 participants took part in interviews or focus groups. A case record audit was undertaken of all births in Scotland during one week in two consecutive years before and after pathway implementation.

Findings

government and health board level commitment to, and support of, the programme signalled its importance and facilitated change. Consultant midwives tailored change strategies, using different approaches in response to the culture of care and inter-professional relationships within contexts. In contexts where practice was already changing KCND was seen as validating and facilitating. In areas where a more medical culture existed there was strong resistance to change from midwives and medical staff and robust implementation strategies were required. Overall the pathways appeared to enable midwives to achieve change.

Key conclusions

our study highlighted the importance of those involved in a change programme working across levels of hierarchy within an organisation and from the macro-context of national policy and institutions to the meso-context of regional health service delivery and the micro-context of practitioner's experiences of providing care. The assumptions and propositions that inform programmes of change, which are often left at a tacit level and unexamined by those charged with implementing them, were made explicit. This examination illuminated the roles of the three key change mechanisms adopted in the KCND programme – appointment of consultant midwives as programme champions, multidisciplinary care pathways, and midwife-led care. It revealed the role of the commitment mechanism, which built on the appointment of the local change champions. The analysis indicated that the process of change, despite these clear mechanisms, needed to be adapted to local contexts and responses to the implementation of KCND.

Implications for practice

initial formative evaluation should be conducted prior to development of complex healthcare programmes to ensure that (1) the interventions will address the changes required, (2) key stakeholders who may support or resist change are identified, and (3) appropriate facilitation strategies are developed tailored to context.     

Birth preparedness and skilled attendance at birth in Nepal: Implications for achieving millennium development goal 5

Objective

to assess birth preparedness in expectant mothers and to evaluate its association with skilled attendance at birth in central Nepal.

Design

a community-based prospective cohort study using structured questionnaires.

Setting

Kaski district of Nepal.

Participants

a total of 701 pregnant women of more than 5 months gestation were recruited and interviewed, followed by a second interview within 45 days of delivery.

Measurements

outcome was skilled attendance at birth. Birth preparedness was measured by five indicators: identification of delivery place, identification of transport, identification of blood donor, money saving and antenatal care check-up.

Findings

level of birth preparedness was high with 65% of the women reported preparing for at least 4 of the 5 arrangements. It appears that the more arrangements made, the more likely were the women to have skilled attendance at birth (OR=1.51, p<0.001). For those pregnant women who intended to save money, identified a delivery place or identified a potential blood donor, their likelihood of actual delivery at a health facility increased by two to three fold. However, making arrangements for transportation and antenatal care check-up were not significantly associated with skilled attendance at birth.

Conclusions

intention to deliver in a health-care facility as measured by birth preparedness indicators was associated with actual skilled attendance at birth. Birth preparedness packages could increase the proportion of skilled attendance at birth in the pathway of meeting the Millennium Development Goal 5.     

Exposure to life-threatening stressful situations and the risk of preterm birth and low birth weight

Objective

To evaluate the association between exposure to life-threatening rocket attacks and the risks of preterm birth (PTB) and low birth weight (LBW).

Methods

The present retrospective cohort study compared the outcomes of 1851 births by women exposed to rocket attacks and 2979 births by unexposed women. The timing, frequency, and intensity of exposure were calculated for each trimester and for the entire pregnancy period. Demographic and medical data were abstracted from the patients’ records.

Results

The rates of PTB and LBW were higher among exposed than unexposed women (PTB: 9.1% versus 6.8%, P = 0.004; LBW: 7.6% versus 5.8%, P = 0.02). The rate of infants who were small for gestational age did not differ between the groups. After controlling for potential confounders, the risks for PTB and LBW remained significantly higher in the exposed group (PTB: adjusted odds ratio 1.3 [95% confidence interval, 1.1–1.7]; LBW: adjusted odds ratio 1.3 [95% confidence interval, 1.03–1.7]). There was no linear association between the intensity of exposure and the risk of PTB or LBW.

Conclusion

Maternal exposure to intermittent but repeated life-threatening rocket attacks for a prolonged period might be associated with increased risks of PTB and LBW.     

Factors associated with maternal intrapartum transfers from a freestanding birth centre in São Paulo,Brazil: A case control study

Objectives

to identify factors associated with maternal intrapartum transfer from a freestanding birth centre to hospital.

Design

case-control study with retrospective data collection.

Participants and settings

cases included all 111 women transferred from a freestanding birth centre in Sao Paulo to the referral hospital, from March 2002 to December 2009. The controls were 456 women who gave birth in the birth centre during the same period who were not transferred, randomly selected with four controls for each case.

Methods

data were obtained from maternal records. Factors associated with maternal intrapartum transfers were initially analysed using a χ² test of association. Variables with p<0.20 were then included in multivariate analyses. A multiple logistic regression model was built using stepwise forward selection; variables which reached statistical significance at p<0.05 were considered to be independently associated with maternal transfer.

Findings

during the study data collection period, 111 (4%) of 2,736 women admitted to the centre were transferred intrapartum. Variables identified as independently associated factors for intrapartum transfer included nulliparity (OR 5.1, 95% CI 2.7–9.8), maternal age ≥35 years (OR 5.4, 95% CI 2.1–13.4), not having a partner (OR 2.8, 95% CI 1.5–5.3), cervical dilation ≤3 cm on admission to the birth centre (OR 1.9, 95% CI 1.1–3.2) and between 5 and 12 antenatal appointments at the birth centre (OR 3.8, 95% CI 1.9–7.5). In contrast, a low correlation between fundal height and pregnancy gestation (OR 0.3, 95% CI 0.2–0.6) appeared to be protective against transfer.

Conclusions and implications for practice

identifying factors associated with maternal intrapartum transfer could support decision making by women considering options for place of birth, and support the content of appropriate information about criteria for admission to a birth centre. Findings add to the evidence base to support identification of women in early labour who may experience later complications and could support timely implementation of appropriate interventions associated with reducing transfer rates.     

‘Reacting to the unknown’: experiencing the first birth at home or in hospital in Australia

Objective

to explore the experiences of a small group of first-time mothers giving birth at home or in hospital.

Design

a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes.

Setting

Sydney, Australia.

Participants

19 women were interviewed. Seven women who gave birth for the first time in a public hospital and seven women who gave birth for the first time at home were interviewed, and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once.

Results

these women shared common experiences of giving birth as ‘novices’. Regardless of birth setting, they were all ‘reacting to the unknown’. As they entered labour, the women chose different levels of responsibility for their birth. They also readjusted their expectations when the reality of labour occurred, reacted to the ‘force’ of labour, and connected or disconnected from the labour and eventually the baby.

Implications for practice

knowing that first-time mothers, irrespective of birth setting, are essentially ‘reacting to the unknown’ as they negotiate the experience of birth, could alter the way in which care is provided and increase the sensitivity of midwives to women's needs. Most importantly, midwives need to be aware of the need to help women adjust their expectations during labour and birth. Identifying the ‘novice’ status of first-time mothers also better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing.     

Recent oral contraceptive use and adverse birth outcomes

Objective

To examine the possible association between oral contraceptive use and adverse birth outcomes.

Study design

We conducted a population-based cohort study of pregnant women who used oral contraceptives within 3 months before their last menstrual period. Subjects were divided into three groups, according to the interval (0–30, 31–60, and 61–90 days) between the dispensing date and their last menstrual period. For each exposed subject, 4 subjects without exposure to oral contraceptives were individually matched by infant's year of birth and plurality and by mother's age and parity.

Results

Oral contraceptive use within 30 days prior to the last menstrual period was associated with increased risks of very low birth weight (OR: 3.24, 95% CI: 1.18, 8.92), low birth weight (OR: 1.93, 95% CI: 1.17, 3.20), and preterm birth (OR: 1.61, 95% CI: 1.01, 2.55); however, oral contraceptive use 31–90 days prior to the last menstrual period did not increase the risk of low birth weight or preterm birth.

Conclusion

Our results indicate the use of oral contraceptives near the time of conception may be associated with an increased risk of low birth weight and preterm birth.     

Perceptions of risk and risk management among 735 women who opted for a home birth

Objective

home birth is not included in the Swedish health-care system and the rate for planned home births is less than one in a thousand. The aim of this study was to describe women's perceptions of risk related to childbirth and the strategies for managing these perceived risks.

Design and setting

a nationwide study including all women who had given birth at home in Sweden was conducted between 1 January 1992 and 31 July 2005.

Participants

a total of 735 women had given birth to 1038 children. Of the 1038 questionnaires sent to the women, 1025 (99%) were returned.

Measurements

two open questions regarding risk related to childbirth and two questions answered using a scale were investigated by content analysis.

Findings

regarding perceived risks about hospital birth, three categories, all related to loss of autonomy, were identified: (1) being in the hands of strangers; (2) being in the hands of routines and unnecessary interventions; and (3) being in the hands of structural conditions. Perceived risks related to a home birth were associated with a sense of being beyond help: (1) worst-case scenario; and (2) distance to the hospital. The perceived risks were managed by using extrovert activities and introvert behaviour, and by avoiding discussions concerning risks with health-care professionals.

Conclusion

women who plan for a home birth in Sweden do consider risks related to childbirth but they avoid talking about the risks with health-care professionals.

Implications for practice

to understand why women choose to give birth at home, health-care professionals must learn about the perceived beneficial effect of doing so.