“Midwives Are Nice,But …”: Perceptions of Midwifery and Childbirth in an Undergraduate Class

Introduction : The purpose of this study was to explore college students' beliefs about childbirth and midwifery. Methods : A critical qualitative analysis was used to identify common themes that occurred in an online class discussion about midwifery. Results : This population of 459 college students drew on the larger social discourse of the medical model of childbirth to frame their discussion of childbirth and midwives. Common beliefs that emerged from class discussions included the perceived dangerous nature of childbirth, the necessity for technologic interventions in childbirth, and doubts about the quality of midwifery training and practice. Discussion : To promote midwifery among this population, advocates should continue public education efforts through a variety of media and communication strategies, with an emphasis on the safety of midwifery care. J Midwifery Womens Health 2010;55:117–123 c̊ 2010 by the American College of Nurse‐Midwives.     

Evaluation of Obstetric Near Miss and Maternal Deaths in a Tertiary Care Hospital in North India: Shifting Focus from Mortality to Morbidity

Objective

Near miss audit improves understanding of determinants of maternal morbidity and mortality and identifies areas of substandard care. It helps health professionals to revise obstetric policies and practices.

Methods

A retrospective review of obstetric case records was performed to assess frequency ad nature of maternal near miss (MNM) cases as per WHO criteria. For each case, primary obstetric complication leading to maternal morbidity was evaluated. Obstetric complications were analyzed to calculate prevalence ratio, case fatality ratio, and mortality index.

Results

There were 6,357 deliveries, 5,273 live births, 247 maternal deaths, and 633 MNM cases. As per WHO criteria for Near miss, shock, bilirubin >6 mg%, and use of vasoactive drugs were the commonest clinical, laboratory, and management parameters. Hemorrhage and hypertensive disorders of pregnancy were leading cause of MNM (45.7 and 24.2 %) and maternal deaths (28.7 and 21.5 %). Highest prevalence rate, case fatality ratio, and mortality index were found in hemorrhage (0.53), respiratory diseases (0.46), and liver disorders (51.9 %), respectively.

Conclusion

Developing countries carry a high burden of maternal mortality and morbidity which may be attributed to improper management of obstetric emergencies at referring hospitals, poor referral practices, and poor access/utilization of health care services.     

Comparison of Fetomaternal Outcome Between Planned Vaginal Delivery and Planned Cesarean Section in Women with Eclampsia: Observational Study

ObjectiveThe route of termination of pregnancy in eclampsia is not clearly established. This study aims to compare the fetomaternal outcome between planned vaginal delivery and planned cesarean section in women with eclampsia after 34 weeks of gestation.MethodsThis prospective observational study was conducted in the department of Obstetrics and Gynecology, Midnapore Medical College, West Bengal, India. 182 women with eclampsia carrying 34 weeks or more gestation were allocated to either cesarean(CD) or vaginal delivery (VD) group. The primary measure of outcome was severe maternal outcome. Secondary measures of outcome were perinatal mortality and morbidity.ResultsOf the 62 women allocated in vaginal delivery (VD) group, 60 women (32.97%) had vaginal delivery and 122 (67.03%) had undergone cesarean delivery (CD). Severe maternal outcome was more common in VD group in comparison with CD group (72.5% vs 27.5%, P < 0.00001 RR 2.64 OR 6.98). Perinatal outcome in relation to Apgar score at 5 min, still birth was better in CD group than VD group. Perinatal death was higher in VD group when compared with CD group (25.8%; vs. 8.33%; P = 0.002, RR 3.1 OR 3.83)ConclusionThere is increasing trend of delivering the eclampsia mother at > 34 weeks of gestation by cesarean section instead of inducing labor and delivering vaginally. Cesarean section when chosen as method of delivery does not increase morbidity or mortality.     

“I Wasn't Alone”—A Study of Group Prenatal Care in the Military

The military has recognized that health and quality of life for service members are closely tied to the resources for their families, including how they are cared for during pregnancy and childbirth. However, there has been little examination of women's experience with different models of prenatal care (PNC) in military settings. The purpose of this article is to describe the results of a qualitative study of women's experiences with the CenteringPregnancy model of group PNC compared to individual PNC in two military health care settings. This clinical trial enrolled 322 women who were randomized into group or individual PNC at two military treatment facilities. Qualitative interviews were completed with 234 women during the postpartum period. Interpretative narrative and thematic analysis was used to identify three themes: 1) “I wasn't alone”—the experience with group PNC; 2) “I liked it but…”—recommendations to improve group PNC; and 3) “They really need to listen”—general concerns across the sample about PNC. Greatest concerns of women in individual PNC included lack of continuity and time with the provider. Our military families must be assured that their health care system meets their needs through personal and family‐centered care. Group PNC offers the potential for continuity of provider while also offering community with other women. In the process, women gain knowledge and power as a health care consumer.     

“The Midwifery Two‐Step”: A Study on Evidence‐Based Midwifery Practice

Introduction: To date, there has been little documentation of how practice‐based midwifery networks in the United States might influence the transfer and development of knowledge in childbearing and women's health care. The first phase of this participatory action research project was to conduct a qualitative study with a community of midwifery practices to understand their perspectives on evidence‐based practice and how an organized network could facilitate their work. Methods: Midwives within the community of interest were invited by letter or e‐mail to participate in individual or small group interviews about knowledge transfer, primary concerns of evidence‐based practice, and potential for a midwifery practice‐based research network. Participatory action research strategies and organizational ethnographic approaches to data collection were used to guide qualitative interviews. Results: Eight midwifery practices enrolled in the study with 23 midwives participating in interviews. They attended births at 2 hospitals in the community. Two broad areas of discourse about evidence‐based practice were identified: 1) challenges from influential persons, finances and resources, and the cultural perception of midwifery, and 2) strategies to foster best practice in the face of those challenges. The midwives believed a research network could be useful in learning collectively about their practices and in the support of their work. Discussion: Evidence‐based practice is a goal but also has many challenges in everyday implementation. Practice‐based research networks hold promise to support clinicians to examine the evidence and form strong coalitions to foster best clinical practice. The second phase of this study will work with this community of midwives to explore collective strategies to examine and improve practice.     

Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Are There “Unnecessary” Cesarean Sections? Perceptions of Women and Obstetricians About Cesarean Sections for Nonclinical Indications

ABSTRACT: Background: The belief that many women demand cesarean sections in the absence of clinical indications appears to be pervasive. The aim of this study was to examine whether, and in what context, maternal requests for cesarean section are made. Methods: Quantitative and qualitative methods were used. The overall study comprised 4 substudies: 23 multiparous and 41 primiparous pregnant women were asked to complete diaries recording events related to birth planning and expectations; 44 women who had considered, or been asked to consider, cesarean section during pregnancy were interviewed postnatally; 24 consultants and registrars in 3 district hospitals and 1 city hospital were interviewed; 5 consultants with known strong views about cesarean section were also interviewed; and 785 consultants from the United Kingdom and Eire completed postal questionnaires. Results: No woman requested cesarean section in the absence of, what she considered, clinical or psychological indications. Fear for themselves or their baby appeared to be major factors behind women’s requests for cesarean section, coupled with the belief that cesarean section was safest for the baby. Most obstetricians reported few requests for cesarean section, but nevertheless, cited maternal request as the most important factor affecting the national rising cesarean section rate. Several obstetricians discussed the significance of women’s fears and the importance of taking the time to talk to women about these fears. Conclusions: Existing evidence for large numbers of women requesting cesarean sections in the absence of clinical indications is weak. This study supports the thesis that these women comprise a small minority. Psychological issues and maternal perceptions of risk appear to be significant factors in many maternal requests. Despite this finding, maternal request is perceived by obstetricians to be a major factor in driving the cesarean section rate upward. (BIRTH 34:1 March 2007)     

An Evaluation of Pain and “Fitness” During Labor and Its Acceptability to Women

Abstract: Background : Labor experiences involve many dimensions that change during labor but are rarely measured contemporaneously and longitudinally. We examined pain and “fitness” aspects of women's labor experience and assessed the acceptability to participants. Methods : Thirty nulliparas and 20 multiparas in term labor indicated pain and fitness every 45 minutes in contraction‐free intervals on visual analog scales from 0 to 10. Fitness implied both physical and psychological strength. Data were analyzed cross‐sectionally and longitudinally, with adjustment for analgesia and time dependency. Women received feedback and evaluated their participation on the first day postpartum. Results : Measurements of pain and fitness ranged from 2 to 22 per woman (mean ± SD: 7.4 ± 4.4). Pain scores showed various patterns, mostly increasing from 1.4 (± 1.9) at the first to 6.6 (± 3.8) at the last measurement in nulliparas and from 1.3 (± 2.1) to 6.2 (± 4.0) in multiparas. One half of the women declined steadily in fitness throughout labor, occasionally after a slight increase early on. Multiparas entered labor more fit (5.9 ± 3.0) than nulliparas (3.9 ± 2.7), but showed a sharper decline so that the difference leveled out just before birth. Although fitness at any one time did not reflect pain levels, fitness and pain were inversely related, especially in nulliparas (p = 0.003). Analgesia affected pain scores but affected fitness only a little. Women's responses were mainly positive, especially in appreciating the feedback. Nevertheless, 32 percent of women skipped one or more measurements, often toward the end or when too close to a contraction. Conclusions : Pain and “fitness” are two distinctly different dimensions of labor experience. Repeated longitudinal measurements of elements of well‐being are clearly feasible and acceptable to laboring women. They may be useful to assess how labor events and interventions affect women's well‐being.     

Cesarean Section Rates and Maternal and Neonatal Mortality in Low‐, Medium‐, and High‐Income Countries: An Ecological Study

ABSTRACT: Background: Cesarean section rates show a wide variation among countries in the world, ranging from 0.4 to 40 percent, and a continuous rise in the trend has been observed in the past 30 years. Our aim was to explore the association of cesarean section rates of different countries with their maternal and neonatal mortality and to test the hypothesis that in low‐income countries, increasing cesarean section rates were associated with reductions in both outcomes, whereas in high‐income countries, such association did not exist. Methods: We performed a cross‐sectional multigroup ecological study using data from 119 countries from 1991 to 2003. These countries were classified into 3 categories: low‐income (59 countries), medium‐income (31 countries), and high‐income (29 countries) countries according to an international classification. We assessed the ecological association between national cesarean section rates and maternal and neonatal mortality by fitting multiple linear regression models. Results: Median cesarean section rates were lower in low‐income than in medium‐ and high‐income countries. Seventy‐six percent of the low‐income countries, 16 percent of the medium‐income countries, and 3 percent of high‐income countries showed cesarean section rates between 0 and 10 percent. Three percent of low‐income countries, 36 percent of medium‐income countries, and 31 percent of high‐income countries showed cesarean section rates above 20 percent. In low‐income countries, a negative and statistically significant linear correlation was observed between cesarean section rates and neonatal mortality and between cesarean section rates and maternal mortality. No association was observed in medium‐ and high‐income countries for either neonatal mortality or maternal mortality. Conclusions: No association between cesarean section rates and maternal or neonatal mortality was shown in medium‐ and high‐income countries. Thus, it becomes relevant for future good‐quality research to assess the effect of the high figures of cesarean section rates on maternal and neonatal morbidity. For low‐income countries, and on confirmation by further research, making cesarean section available for high‐risk pregnancies could contribute to improve maternal and neonatal outcomes, whereas a system of care with cesarean section rates below 10 percent would be unlikely to cover their needs. (BIRTH 33:4 December 2006)     

“Universal Precautions”: Perinatal Touch and Examination after Childhood Sexual Abuse

Background: Childhood sexual abuse is a common experience of Australian women with 1 woman in 3 reporting unwanted sexual activity, and 1 in 10 reporting attempted or penetrative sexual abuse before 16 years of age. The objective of this study was to explore women's responses to perinatal professional touch and examination of themselves and their babies. Methods: Eighteen women were interviewed using an in‐depth semistructured qualitative method. Interviews were recorded and transcribed. The interviews were coded and thematically analyzed, using NVivo to assist with data management. To ensure rigor, four initial interviews were coded by a second researcher and discrepancies resolved. Results: Two key themes were identified by childhood sexual abuse survivors as important in improving service provision: safety issues for survivors and their babies in the clinical encounter and ways of making service provision safer. Conclusions: Childhood sexual abuse survivors experienced pain, dissociation, fear, blame, helplessness, and guilt in their encounters with health care practitioners. These experiences led to the development of a set of “Universal Precautions” for perinatal professionals responding to women and their children.