Maternity Care Providers Research Articles

P22 - Negotiating the system: Women’s experiences of antenatal exclusion from publicly-funded homebirth

Strict eligibility criteria for publicly-funded homebirth models mean that many women planning a homebirth are later excluded. At present, little is known about women’s experience of antenatal exclusion from these models. Fifteen publicly-funded homebirth programs are operating in Australia, offering eligible women the opportunity to give birth at home at no cost, with the care of a hospital-employed midwife. The model has previously been positively evaluated by childbearing women and the midwives who work in them. This presentation will share findings from research exploring the experiences of women who planned a publicly-funded homebirth and were later excluded due to pregnancy complications or risk factors. This study employed a qualitative descriptive approach. Recruitment was via social media sites specifically related to homebirth in Australia. Data collection involved semi-structured telephone interviews with transcripts being thematically analysed by the research team. Thirteen women participated. Antenatal exclusion from a publicly-funded homebirth program can be distressing and women may wish to continue their plans to give birth at home. Some women feel coerced and bullied into following hospital protocols that are not tailored to their individual circumstances. Maintaining the midwife-mother relationship acts as a protective factor, ameliorating some of the negative effects caused by changing a woman’s planned place of birth. Women plan a homebirth to avoid the medicalised hospital environment and to gain access to continuity of midwifery care. To provide maternity care that is acceptable to women, hospital institutions need to design services that enable continuity of the midwife-mother relationship and assess risk on an individual basis. Exclusion from publicly-funded homebirth has the potential to negatively impact women who may feel a sense of loss, uncertainty or emotional distress related to their planned place of birth.

Insider knowledge as a double-edged sword: an integrative review of midwives’ personal childbearing experiences

BackgroundThe majority of maternity care is provided by female midwives who have either become mothers or are of childbearing age, but there is limited research exploring midwives’ own personal childbearing experiences. This integrative review aims to explore the published literature and research on midwives’ own experiences of pregnancy and childbirth.MethodAn integrative review of the literature was conducted after relevant articles were identified through a search of: five electronic databases (Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, and Google Scholar), cited reference lists, and networking with peers. Similar and contrasting patterns and relations within the literature were identified and grouped into themes and subthemes.ResultsTwenty articles were included in the review and four overarching themes were identified. Insider knowledge plays a role in decision making encompassed the way midwives used their knowledge to choose; a preferred mode of birth, maternity care provider, model of care, and place of birth. Navigating the childbirth journey demonstrated how some midwives were able to use their insider knowledge to achieve agency, while others had difficulty achieving agency. This theme also revealed the ‘midwife brain’ that midwives need to manage during their childbearing journey. The theme impact of care on the birth experience described how the type of care the midwives received from maternity care providers affected their overall birth experience. The fourth theme from midwife to mother explains their preparedness for childbirth and their transition to motherhood.ConclusionFor childbearing midwives, there is a potential conflict between their position as knowledgeable experts in maternity care, and their experience as mothers. Whilst they can use their insider knowledge to their advantage, they also experience heightened fear and anxiety through their pregnancy. It is important for maternity care providers to acknowledge and support them and provide balanced and tailored care that acknowledges the woman within the professional midwife and the professional midwife within the woman.

Knowledge, experiences and attitudes of midwives in maternity care in encounters with pregnant women with obesity - are adverse childhood experiences understood and explored as a contributing factor?

ObjectiveTo explore knowledge, experiences and attitudes of midwives in maternity care in encounters with pregnant women with obesity, and whether they investigate adverse childhood experiences as a contributing factor to the weight challenges. DesignSemi-structured interviews were undertaken to explore midwives’ experiences of providing maternity care for women with obesity. For data analysis, Malterud's systematic text condensation was used, a method for thematic cross-case analysis of qualitative data with an inductive approach. Participants and settingNine midwives working in maternity care in Central Norway. The interviews were conducted online or at the midwives’ workplace. FindingsThe midwives routinely investigated pregnant women's childhood, but few saw a link between adverse childhood experiences and obesity. Pregnant women with obesity were perceived by the midwives as particularly vulnerable, which led to a sensitive, individualised approach focusing on trust and relationship building. This approach, in addition to pointing out complications that can occur with obesity, was described as a balancing act. The midwives described preventative healthcare as a natural task, but hectic days with many competing tasks were seen as an obstacle. The women's motivation for lifestyle change was experienced differently by the midwives; some described strong motivation while others mentioned poor motivation. The midwives found it reassuring to have experience to draw on in broaching difficult topics. Key conclusions and implications for practiceMidwives’ many years of experience enable them to approach obese pregnant women in an individual and careful way. Their mission in public health could be better utilised if they explored negative childhood experiences in relation to pregnant women's weight challenges.

Gaza midwives' experiences in providing maternity care during COVID-19.

INTRODUCTIONThe Gaza Strip is densely populated. The COVID-19 pandemic has had a detrimental impact on global healthcare systems, and midwifery practices have transformed in maternity care settings. Our research aimed at understanding the Palestinian midwives’ experiences in providing maternity care in Gaza during the COVID-19 pandemic at Gaza European Hospital which was the only hospital providing care for people diagnosed with COVID-19.METHODSTo understand the phenomenon of interest, descriptive phenomenology was used. A purposive sample of eight midwives from the European Gaza Hospital was chosen. Between December 2020 and January 2021, semi-structured interviews were used in the data collection procedure. The collected data were analyzed using the Colaizzi approach.RESULTSThe investigation resulted in three main themes: emotionally overwhelmed, work environment challenges, and interpersonal relationship development.CONCLUSIONSMidwives shared both positive and negative experiences from their time working in the European Gaza Hospital during the COVID-19 pandemic. They were confronted with negative emotions such as fear, stress, and anxiety, as well as environmental challenges. Despite this, they created a new interpersonal bond that was positively reflected. To sustain their psychological well-being, COVID-19 care workers require psychological support at work. A strong need exists for equipping the Maternity Department with the essential equipment and supplies to reduce the working environment load, as well as giving the necessary training to staff to be qualified enough to provide such crucial care.

Mixed-Methods Study of the Experience of Pregnancy During the COVID-19 Pandemic

ObjectiveTo understand the experiences of women who were pregnant during the initial stage of the COVID-19 pandemic, March 2020 to May 2020, and how they coped with stress. DesignA convergent mixed-methods design. SettingOnline survey that launched in April 2020. ParticipantsA total of 185 pregnant women. MethodsFor the quantitative strand, we measured adaptation to coping with stress using the Brief Resilient Coping Scale. For the qualitative strand, we asked participants to describe the experience of being pregnant during the pandemic. ResultsThe mean score on the Brief Resilient Coping Scale was 14.7, which indicated a medium-level resilient coper. Using Krippendorff’s content analysis, we identified four themes: Robbed of Enjoying the Expected Pregnancy Experiences, Anxiety and Fear in the Face of a Pandemic Pregnancy, Heightened Source of Worry With Birth on the Horizon, and Choosing Hope. ConclusionTo meet the needs of pregnant women, perinatal nurses and other maternity care providers must understand the experience of pregnancy during times of upheaval, such as the onset of a global pandemic. Health care providers and nurses can help ensure ideal outcomes for pregnant women by recognizing the loss of the expected pregnancy experience, providing support through creative social outlets, and fostering hopeful optimism.

A survey of perceived traumatic birth experiences in an Irish maternity sample – prevalence, risk factors and follow up

ObjectivesTo establish the prevalence and correlates of a subjectively traumatic birth experience in an Irish maternity sample. DesignA questionnaire routinely provided to all women prior to hospital discharge post-birth was amended for data collection for this study. Two additional questions seeking information about women's perceptions of their birth were added and analysed. Women who described their birth as traumatic and agreed to follow-up, received a City Birth Trauma Scale (Ayers et al., 2018) at subsequent follow-up (6 to 12 weeks postpartum). Demographic, obstetric, neonatal variables and factors associated with birth trauma were collected from electronic maternity records retrospectively. SettingA postnatal ward in an Irish maternity hospital which provides postnatal care for public maternity patients. ParticipantsPostpartum women (N=1154) between 1 and 5 days postpartum. Measurements & findingsParticipants completed the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) with two additional questions about birth trauma. Eighteen percent (n=209) of women reported their birth as traumatic. Factors associated with reporting birth as traumatic included a history of depression, raised EPDS scores (>12), induction of labour, combined ventouse/forceps birth, and postpartum haemorrhage. Of these 209 women, 134 went on to complete the City Birth Trauma Scale (Ayers et al., 2018). The average score was 3.84 and 6 of this sample (4%) reached the threshold for postpartum post-traumatic stress disorder (PTSD). Key conclusionsThis study identified a prevalence of 18% of women experiencing birth as traumatic and the potentially important role of a current and past history of depression, postpartum haemorrhage, induction of labour and operative vaginal birth in defining a traumatic birth experience. The majority of women were resilient to birth trauma, few developed PTSD , but a larger cohort had significant functional impairment associated with sub-clinical postpartum PTSD symptoms. Implications for practiceMaternity care providers should be aware of the risk factors for traumatic birth. Introducing a trauma–informed approach amongst midwives and maternity care providers in the postnatal period may help to detect emerging or established persisting trauma-related symptoms. For women with sub-clinical postpartum PTSD symptoms a detailed enquiry may be more effective in identifying postpartum PTSD at a later postnatal stage e.g., at six weeks postpartum. Maternity services should provide ongoing supports for women who have experienced birth trauma.

Health system bottlenecks hindering provision of supportive and dignified maternity care in public health facilities.

Mistreatment with women during childbirth is prevalent in many in low- and middle-income countries. There is dearth of evidence that informs development of health system interventions to promote supportive and respectful maternity care in facility-based settings. We examined health systems bottlenecks that impedes provision of supportive and respectful maternity care in secondary-level public healthcare system of Pakistan. Using a qualitative exploratory design, forty in-depth interviews conducted with maternity care staff of six public health facilities in southern Pakistan. Development of interview guide and data analyses were guided by the WHO's six health system building blocks. A combination of inductive and deductive approach was used for data analyses. Our study identified range of bottlenecks impeding provision of RMC. In terms of leadership/governance, there was lack of institutional guidelines, supervision and monitoring, and patient feedback mechanism. No systematic mechanism existed to screen and record patient psychosocial needs. Health workforce lacked training opportunities on RMC that resulted in limited knowledge and skills; there were also concerns about lack of recognition from leadership for good performers, and poor relationship and coordination between clinical and non-clinical staff. Regarding the domain of service delivery, we found that patients were perceived as un-cooperative, non-RMC manifestations were acceptable and normalized under certain conditions, and restrictive policies for active engagement of companions. Finally, lack of cleanliness, curtains for privacy, seating arrangement for companion were the identified issues infrastructural issues. A service-delivery intervention package is needed that effectively uses all six components of the health system: from investments in capacity building of maternity teams to creating a conducive facility environment via proper governance and accountability mechanisms. Such interventions should not only focus on provision of maternity care in a respectful and dignified manner, but also ensure that care is responsive to the psychosocial needs of pregnant women without any discrimination.

Documenting surgical triage in rural surgical networks: Formalising existing structures.

It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection. Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis. Six community hospitals in British Columbia, Canada. General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists. Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources. Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.

“Who am I to say?” Dutch care providers' evaluation of psychosocial vulnerability in pregnant women

Maternity care increasingly focuses on evaluating psychosocial vulnerability during pregnancy. Research and nationwide (public health) programs, both in the USA and Europe, led to the development of new protocols and screening instruments for care providers to systematically screen for psychosocial vulnerability in pregnant women. However, standardised screening for vulnerability is complex since it requires discussion of sensitive issues. Women may fear stigmatisation and may have limited trust in their care providers or the health system. Our study contributes to the growing field of client-facing risk work by exploring care providers' interpretations and evaluation of psychosocial vulnerability in pregnant women. Drawing on semi-structured interviews with Dutch maternity care providers, we explore how they conceptualise risk and vulnerability and identify ‘vulnerable pregnant women’ in their practices. We find that care providers conceptualise ‘vulnerability’ as primarily based on risk, which contributes to an imbalanced focus on individual mothers, rather than on both parents and the social context. Our findings highlight care providers' concerns around ‘care avoidance’, seen as a risk factor affecting ‘vulnerability’ during pregnancy and as a possible consequence of risk screening. The care providers we interviewed employ “in between-strategies” based on intuition, emotion, and trust to skillfully attend to the risk that comes with risk work, in terms of its potential impact on relationships of trust and open communication. We conclude that ‘vulnerability’ should be understood as a multi-layered, situated and relational concept rather than simply as an epidemiological category. Since a trusting relationship between pregnant women and care providers is crucial for the evaluation of vulnerability, we reflect critically on the risk of standardised perinatal psychosocial risk evaluations. Policy should recognise providers' “in between-strategies” to embed epidemiological understandings of risk in the context of everyday risk work.

Getting kicked off the program: Women’s experiences of antenatal exclusion from publicly-funded homebirth in Australia

ProblemEligibility criteria for publicly-funded homebirth models are strict and, as such, many women who initially plan a homebirth later become excluded. BackgroundFifteen publicly-funded homebirth programs are operating in Australia, offering eligible women the opportunity to give birth at home at no cost, with the care of a hospital-employed midwife. AimTo explore the experiences of women who planned a publicly-funded homebirth and were later excluded due to pregnancy complications or risk factors. MethodsA qualitative descriptive approach was taken. Recruitment was via social media sites specifically related to homebirth in Australia. Data collection involved semi-structured telephone interviews. Transcripts were thematically analysed. FindingsThirteen women participated. They were anxious about ‘Jumping through hoops’ to maintain their low-risk status. After being ‘Kicked off the program’, women carefully 'negotiated the system’ in order to get the birth they wanted in hospital. Some women felt bullied and coerced into complying with hospital protocols that did not account for their individual needs. Maintaining the midwife-woman relationship was a protective factor, decreasing negative experiences. DiscussionWomen plan a homebirth to avoid the medicalised hospital environment and to gain access to continuity of midwifery care. To provide maternity care that is acceptable to women, hospital institutions need to design services that enable continuity of the midwife-woman relationship and assess risk on an individual basis. ConclusionExclusion from publicly-funded homebirth has the potential to negatively impact women who may feel a sense of loss, uncertainty or emotional distress related to their planned place of birth.

Effect of intervention delivered by frontline maternal care providers to improve outcome and parenting skills among adolescents with perinatal depression in Nigeria (the RAPiD study): A cluster randomized controlled trial

BackgroundPerinatal depression is more common and is associated with greater negative consequences among adolescents than adults. Psychosocial interventions designed for adults may be inadequate at addressing the unique features of adolescent perinatal depression. MethodsIn a two-arm parallel cluster randomized trial conducted in thirty primary maternal care clinics in Ibadan, Nigeria (15-intervention and 15-control) we compared age-appropriate intervention consisting of problem-solving therapy, behavioral activation, parenting skills training, and parenting support from a self-identified adult to care as usual. Pregnant adolescents (aged <20 years) at fetal gestational age16–36 weeks with moderate to severe depression were recruited. Primary outcomes were depression symptoms (Edinburgh Postnatal Depression Scale, EPDS) and parenting practices (Infant-Toddler version of the Home Inventory for Measurement of the Environment, HOME-IT) at six-months postnatal. ResultsThere were 242 participants (intervention arm: 141; Control arm: 101), with a mean age of 18∙0 (SD-1∙2). Baseline mean EPDS score was 14∙2 (SD-2.1); 80∙1 % completed the six-month postnatal follow-up. The intervention group had lower level of depressive symptoms than the control group, mean EPDS scores: 5∙5 (SD-3∙6) versus 7∙2 (SD-4∙0) (adjusted mean difference -1∙84 (95%CI- 3∙06 to −0∙62; p = 0∙003) and better parenting practices, mean total HOME-IT scores: 29∙8 (SD-4∙4) versus 26∙4 (SD-4∙2) (adjusted mean difference 3∙4 (95%Cl- 2∙12 to 4∙69, p = 0∙001). LimitationsThis study explored the effect of complex interventions making it difficult to know precisely what aspects produced the outcomes. ConclusionsAn age-appropriate psychosocial intervention package holds promise for scaling up care for adolescents with perinatal depression especially in resource-constrained settings. Trial registrationISRCTN16775958. Registered on 30 April 2019.

Reported information sharing and satisfaction with maternity care providers during the COVID-19 pandemic: Associations with socioeconomic status and shifts to telehealth.

BackgroundThe COVID‐19 pandemic has dramatically affected pregnant people’s prenatal care, labor, and delivery experiences. Given these rapid changes, providers have needed to be proactive in sharing information about COVID‐19‐related care impacts. The purpose of this study was to investigate: (a) Whether patient demographics or disrupted care (eg, canceled appointments and rapid shift to telehealth) is associated with patient‐reported information sharing from the providers; and (b) Whether patient‐reported provider information sharing or disruptions to care are associated with patient satisfaction with provider.MethodsData come from a convenience sample of 1999 pregnant people living in the United States who completed an online survey between April 16 and May 7 2020.ResultsThirty‐eight percent of participants said that their provider had not discussed how the pandemic would affect their care during pregnancy, labor, or delivery. Participants with lower education, less income, or whose appointments had been canceled or rescheduled because of the pandemic were significantly less likely to report information sharing. Provider satisfaction was significantly lower among participants who did not report information sharing, those who had appointments by way of telehealth, and those who reported that all their appointments had been rescheduled/canceled.DiscussionAt the beginning of the pandemic, there were significant socioeconomic inequities in reported information sharing by the providers, which in turn was negatively associated with provider satisfaction. Providers need to be aware of the role implicit bias may play in information sharing—both generally and during public health crises—and consider ways to reduce the impacts of disrupted care delivery on patient satisfaction. If left unaddressed, perceived poor provider communication and associated low satisfaction with providers could contribute to adverse perinatal outcomes.

Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study.

ObjectiveTo assess the association between hospital‐level rates of induction of labour and emergency caesarean section, as measures of ‘practice style’, and rates of adverse perinatal outcomes.DesignNational study using electronic maternity records.SettingEnglish National Health Service.SampleHospitals providing maternity care to women between April 2015 and March 2017.Main outcome measuresStillbirth, admission to a neonatal intensive care unit and babies receiving mechanical ventilation.ResultsAmong singleton term births, the risk of stillbirth was 0.15%, the risk of admission to a neonatal intensive care unit was 5.4% and the risk of mechanical ventilation 0.54%. There was considerable between‐hospital variation in the rate of induction of labour (minimum 17.5%, maximum 40.7%) and in the rate of emergency caesarean section (minimum 5.6%, maximum 17.1%). Women who gave birth in hospitals with a higher rate of induction of labour had better perinatal outcomes. For each 5%‐point increase in induction, there was a decrease in the risk of term stillbirth of 9% (OR 0.91, 95% CI 0.85–0.97) and a decrease in the risk of mechanical ventilation of 14% (OR 0.86, 95% CI 0.79–0.94). There was no significant association between hospital‐level induction of labour rates and neonatal unit admission at term (p > 0.05). There was no significant association between hospital‐level rates of emergency caesarean section and adverse perinatal outcomes (all with p > 0.05).ConclusionsThere is considerable between‐hospital variation in the use of induction of labour and emergency caesarean section. Hospitals with a higher rate of induction had a lower risk of adverse birth outcomes. A similar association was not found for caesarean section.

Multilevel determinants of racial/ethnic disparities in severe maternal morbidity and mortality in the context of the COVID-19 pandemic in the USA: protocol for a concurrent triangulation, mixed-methods study

IntroductionThe COVID-19 pandemic has affected communities of colour the hardest. Non-Hispanic black and Hispanic pregnant women appear to have disproportionate SARS-CoV-2 infection and death rates.Methods and analysisWe will use the...

Persistent maternal tachycardia: A clinical alert for healthcare professionals providing maternity care in South Africa

Cardiac disease is one of the commonest causes of indirect maternal deaths globally. This brief report is a reminder that isolated maternal tachycardia at rest is a clinical alert and warrants a detailed history in relation to cardiac disorders, thorough clinical examination of all organ systems, relevant investigations such as imaging, and expert advice to avoid serious adverse events. We reflect on a belatedly investigated persistent maternal tachycardia resulting in a fatal postpartum collapse due to mitral stenosis. The lost window of opportunity for appropriate investigation and management of the tachycardia provides an insight into many similar maternal deaths in South Africa. Key clinical messages regarding persistent maternal tachycardia are presented for midwives and doctors caring for pregnant women.

Maternity care during COVID-19: a qualitative evidence synthesis of women’s and maternity care providers’ views and experiences

BackgroundAs COVID-19 continued to impact society and health, maternity care, as with many other healthcare sectors across the globe, experienced tumultuous changes. These changes have the potential to considerably impact on the experience of maternity care. To gain insight and understanding of the experience of maternity care during COVID-19, from the perspectives of women and maternity care providers, we undertook a qualitative evidence synthesis (QES).MethodsThe population of interest for the QES were pregnant and postpartum women, and maternity care providers, who provided qualitative data on their experiences of maternity care during COVID-19. The electronic databases of MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane COVID study register were systematically searched from 01 Jan 2020 to 13 June 2021. The methodological quality of the included studies was appraised using a modified version of the quality assessment tool, based on 12-criteria, designed by the Evidence for Policy and Practice Information coordinating Centre (EPPI-Centre). Data were extracted by two reviewers independently and synthesised using the Thomas and Harden framework. Confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual).ResultsFifty records relating to 48 studies, involving 9,348 women and 2,538 maternity care providers, were included in the QES. The methodological quality of the studies varied from four studies meeting all 12 quality criteria to two studies meeting one quality criterion only. The synthesis revealed eight prominent themes. Five of these reflected women’s experiences: 1) Altered maternity care (women), 2) COVID-related restrictions, 3) Infection prevention and risk, 4) ‘the lived reality’ – navigating support systems, and 5) Interactions with maternity services. Three themes reflected maternity care providers’ experiences: 6) Altered maternity care (providers), 7) Professional and personal impact, and 8) Broader structural impact. Confidence in the findings was high or moderate.ConclusionAlthough some positive experiences were identified, overall, this QES reveals that maternity care during COVID-19 was negatively experienced by both women and maternity care providers. The pandemic and associated changes evoked an array of emotive states for both populations, many of which have the potential to impact on future health and wellbeing. Resource and care planning to mitigate medium- and longer-term adverse sequelae are required.PROSPERO registrationCRD42021232684.

The healthcare experiences of women with cardiac disease in pregnancy and postpartum: A qualitative study.

IntroductionCardiac disease affects an estimated 1%–4% of all pregnancies and is a leading cause of maternal morbidity and mortality. There is a lack of data on the healthcare experiences of affected women to inform health service delivery and person‐centred care. This study sought to explore and understand the healthcare experiences of women with cardiac disease in pregnancy and postpartum.MethodsThis qualitative study used semi‐structured interviews with women who had cardiac disease in pregnancy or the first 12 months postpartum. Data were analysed using thematic analysis.ResultsParticipants were 25 women with pre‐existing or newly diagnosed acquired, genetic and congenital cardiac disease. Analysis of the interviews highlighted the discrepancy between care aspirations and experiences. The participants had a wide range of cardiac diseases and timing of diagnoses, but had similar healthcare experiences of being dismissed, not receiving the information they required, lack of continuity of care and clinical guidelines and of feeling out of place within a healthcare system that did not accommodate their combined needs as a mother and a cardiac patient.ConclusionThis study identified a lack of person‐centred care and responsiveness of the healthcare system in providing fit‐for‐purpose healthcare for women with complex disease who are pregnant or new mothers. In particular, cardiac and maternity care providers have an opportunity to listen to women who are the experts on their emergent healthcare needs, contributing to development of the knowledge base on the healthcare experiences of having cardiac disease in pregnancy and postpartum.Patient or Public ContributionPublic and patient input into the value and design of the study was gained through NSW Heart Foundation forums, including the Heart Foundation's women's patient group.

Potential benefit of using phenazopyridine to detect multiple vesicovaginal fistulas for primary repairs on medical mission trips in Cote d'Ivoire

Background: Vesicovaginal fistulas are complex medical/surgical issue that may arise after obstructed labor in areas without access to maternal health care providers. In some areas, fistulas have devastating social consequences on the patient. Easier visualization of the fistula during the surgery might contribute to better surgical success. For this purpose, we describe the use of inexpensive, humble methods available in resource-limited areas. The drug phenazopyridine makes urine orange, whereby easing visualization of fistula(s) during surgery. The objective of this study was to determine the effectiveness of phenazopyridine administration in the resource limited settings. Methods: Medical record review was conducted. Data has been prospectively followed from all patients with vesicovaginal fistulas. All cases were staffed by experienced gynecologic oncologists with multiple different medical trainees (American and Ivorian) assisting. For the first 3 mission trips, no phenazopyridine was given pre-operatively. For the fourth to ninth trip, phenazopyridine was given preoperatively along with enhanced recovery medications. All patients had transurethral catheters left in place for 2 weeks that were removed by a medical professional. Imaging was not available and so success of the repair was based on patient reported symptoms after removal. Patient outcomes (subjective success by patient report) were compared between the two groups (without versus with phenazopyridine). Two-tail Chi square statistics with a significance of 0.05 were performed. Results: 53 patients with vesicovaginal fistulas arising after obstructed labor were primarily treated during nine two-week mission trips. Another 5 patients had urethral vaginal fistulas and these were not included in the report. Of the 53 patients, 9 patients also had co-existing rectovaginal fistulas that were repaired at the same time. The first group of 17 vesicovaginal fistulas (no phenazopyridine given) had a success rate of 76.5% (13/17) while the second group (phenazopyridine given) had a success rate of 97.2% (35/36) (p = 0.016). At the same time the rate of multiple vesicovaginal fistulas in the same patient changed from 5.8% (1/17) in the first group to 22.2% (8/36) (p = 0.14). Conclusions: Using phenazopyridine pre-operatively aided the surgeons in diagnosing multiple vesicovaginal fistulas more commonly and may have benefitted patients by leading to a higher surgical success rate.

Effectiveness of an online education intervention to enhance student perceptions of Respectful Maternity Care: A quasi-experimental study

BackgroundChildbearing women's relationship with maternity care providers enhance childbirth outcomes. Students need to understand and offer respectful care. ObjectiveEvaluate effectiveness and impact of an online education intervention on nursing students' perceptions towards respectful maternity care during labour and childbirth in Nepal. DesignA quasi-experimental pre-post design was used. ParticipantsA total of 89 Third Year Bachelor of Nursing students (intervention n = 40; control n = 49) from three participating colleges. MethodsStudents completed online pre and post-test surveys using the Students' Perceptions of Respectful Maternity Care scale and questions about impact of the intervention. The intervention group received six hours of education delivered online (three sessions x three weeks). ANCOVA and non-parametric Wilcoxon signed-rank tests measured effects. ResultsCompared to controls, students in the intervention group reported a significant increase in perceptions towards respectful maternity care (F (1, 86) = 28.19, p < 0.001, ηp2 = 0.25). Participants reported a good understanding of respectful maternity care (75%), positive views about providing such care (82.5%), and a desire to use their new knowledge in practice (65%). ConclusionRelatively few intervention studies to promote respectful maternity care in students have been published. This brief online intervention improved students' perceptions. The intervention package can be integrated into nursing or midwifery curricula and in-service training. A larger study with longer follow-up is needed to support current findings.

Stillbirth and Associated Factors Among Women Who Gave Birth at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia.

BackgroundStillbirth, which accounts for half of all the perinatal mortality, is not counted on policy, program, and investment agendas around the globe. It has been underestimated public health burden, particularly in developing countries. Ethiopia is among the top countries with a large prevalence of stillbirth in the world. However, there is a dearth of study on the current magnitude of stillbirth in the study area. Therefore, this study intended to assess the prevalence of stillbirth and its associated factors to bridge the gap.MethodsA hospital-based retrospective study was conducted from 1 to 28 February 2019 and data were collected by reviewing the chart records of all the women who gave birth in the past 2 years (January 2016 to December 2018) at Hiwot Fana Specialized University Hospital. Data were entered into EpiData version 4.2.0.0 software and transported to SPSS version 23 for analysis. Descriptive statistics such as frequency, mean, and SDs were generated. Determinants of stillbirth were analyzed using a binary logistic regression and presented by adjusted odds ratio (AOR) with a 95% CI.ResultsThe prevalence of stillbirth was 14.5% (95% CI: 11.7%, 17.6%). Low birth weight (AOR = 2.42, 95% CI: 1.23–4.76), prematurity (AOR = 2.10, 95% CI: 1.10–4.01), premature rupture of membranes (AOR = 2.08, 95% CI: 1.14–3.77), antepartum hemorrhage (AOR = 3.33, 95% CI: 1.66–6.67), obstructed labor (AOR = 2.87, 95% CI: 1.48–5.56), and preeclampsia (AOR = 2.91, 95% CI: 1.28–6.62) were an independently associated with stillbirth.ConclusionThe prevalence of stillbirth in this study was high. Low birth weight, preterm birth, premature rupture of membranes, antepartum hemorrhage, obstructed labor, and preeclampsia were independently associated with a stillbirth. Therefore, much study is needed involving different stakeholders to reduce stillbirths by improving the health status of women through the provision of quality maternal care including referral systems.