Normal Childbirth Research Articles

Use of the Extended Parallel Process Model (EPPM) to Predict Iranian Women’s Intention for Vaginal Delivery

To explicate whether knowledge, perception of health threat, efficacy, and personal beliefs act as predictors for women's intention to have a normal vaginal birth. The study uses a mixed approach. Simultaneously, 290 pregnant women who visited prenatal clinics completed the study. Quantitative and qualitative data were collected using a structured questionnaire based on Witte's extended parallel process model and four focus groups, respectively. Women perceived lower risk but higher levels of efficacy. Perceived self-efficacy, severity, and response efficacy were identified as significant predictors of intention to experience vaginal birth. Participants' insufficient knowledge and misconceptions about birth methods were dominant. Two major themes were identified and divided into negative and positive beliefs about vaginal birth. The extended parallel process model provides a useful framework to assess women's intention to have a vaginal birth, especially when it is combined with a qualitative approach. Within Iranian women, self-confident mothers are more likely to intend to deliver vaginally. Prenatal care provides an opportunity for nurses and midwives to explore mothers' beliefs and intended childbirth method prior to offering medical intervention.

Renegotiating inter‐professional boundaries in maternity care: implementing a clinical pathway for normal labour

This article presents findings from a study of a clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK. The study was conducted between 2004 and 2006. The pathway aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. This article focuses on how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors. Data are drawn from semi-participant observation, focus groups and semi-structured interviews with 41 midwives, and semi-structured interviews with five midwifery managers and six doctors, working in two research sites. Whereas some studies have shown how clinical pathways may act as ‘boundary objects’, dissolving professional boundaries, promoting interdisciplinary care and de-differentiating professional identities, the ‘normal labour pathway’ was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal.

Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: A descriptive study

Objectivesto explore reported hospital policies and practices during normal childbirth in maternity wards in Jeddah, Saudi Arabia, to assess and verify whether these practices are evidence-based. Designquantitative design, in the form of a descriptive questionnaire, based on a tool extracted from the literature. Settingnine government hospitals in Jeddah, Saudi Arabia. These hospitals have varied ownership, including Ministry of Health (MOH), military, teaching and other government hospitals. Participantskey individuals responsible for the day-to-day running of the maternity ward. Measurementsnine interviews using descriptive structured questionnaire were conducted. Data were analysed using SPSS for Windows (version 16.0). Findingsthe surveyed hospitals were found to be well equipped to deal with obstetric emergencies, and many follow evidence-based procedures. On average, the caesarean section rate was found to be 22.4%, but with considerable variances between hospitals. Some unnecessary procedures that are known to be ineffective or harmful and that are not recommended for routine use, including pubic shaving, enemas, episiotomy, electronic fetal monitoring (EFM) and intravenous (IV) infusion, were found to be frequently practiced. Only 22% of the hospitals sampled reported allowing a companion to attend labour and childbirth. Key conclusionsmany aspects of recommended EBP were used in the hospitals studied. However, the results of this study clearly indicate that there is wide variation between hospitals in Jeddah, Saudi Arabia in some obstetric practices. Furthermore, the findings suggest that some practices at these hospitals are not supported by evidence as being beneficial for mothers or infants and are positively discouraged under international guidelines. Implications for practicethis study has specific implications for obstetricians, midwives and nurses working in maternity units. It gives an overview of current hospital policies and practices during normal childbirth. It is likely to contribute to improving the health and well-being of women, and have implications for service provision. It could also help in the development of technical information for policy-makers, and health care professionals for normal childbirth care.

Contextual factors as a key to understanding the heterogeneity of effects of a maternal health policy in Burkina Faso?

Burkina Faso implemented a national subsidy for emergency obstetric and neonatal care (EmONC) covering 80% of the cost of normal childbirth in public health facilities. The objective was to increase coverage of facility-based deliveries. After implementation of the EmONC policy, coverage increased across the country, but disparities were observed between districts and between primary healthcare centres (PHC). To understand the variation in coverage, we assessed the contextual factors and the implementation of EmONC in six PHCs in a district. We conducted a contrasted multiple case study. We interviewed women (n = 71), traditional birth attendants (n = 7), clinic management committees (n = 11), and health workers and district health managers (n = 26). Focus groups (n = 62) were conducted within communities. Observations were carried out in the six PHCs. Implementation was nearly homogeneous in the six PHCs but the contexts and human factors appeared to explain the variations observed on the coverage of facility-based deliveries. In the PHCs of Nogo and Tara, the immediate increase in coverage was attributed to health workers' leadership in creatively promoting facility-based deliveries and strengthening relationships of trust with communities, users' positive perceptions of quality of care and the arrival of female professional staff. The change of healthcare team at Iata's PHC and a penalty fee imposed for home births in Belem may have caused the delayed effects there. Finally, the unchanged coverage in the PHCs of Fati and Mata was likely due to lack of promotion of facility-based deliveries, users' negative perceptions of quality of care, and conflicts between health workers and users. Before implementation, decision-makers should perform pilot studies to adapt policies according to contexts and human factors.

Management of Occiput Posterior Position in the Second Stage of Labor: A Survey of Midwifery Practice in Australia

The management of the occiput posterior (OP) position has been controversial for many years. Manual rotation can be performed by midwives and could reduce cesarean sections and instrumental births. We aimed to determine current midwifery views, knowledge, and practice of manual rotation. A de-identified, self-reported questionnaire was e-mailed to all Australian College of Midwives full members (n = 3,997). Of 3,182 surveyed, 57 percent (1,817) responded, of whom 51 percent (920) were currently practicing midwifery. Seventy-seven percent of midwives thought that manual rotation at full dilatation was a valid intervention. Sixty-four percent stated the procedure was acceptable before instrumental delivery, but 30 percent were unsure. Most practicing midwives (93%) had heard of manual rotation, but only 18 percent had performed one in the last year. Midwives would support the routine performance of manual rotation for OP position if it reduced operative births from 68 to 50 percent and would support manual rotation for occiput transverse (OT) position if it reduced operative births from 39 to 25 percent. This study indicates that manual rotation is considered acceptable by most midwives in Australia, yet is only performed by a minority. Midwives would be willing to perform prophylactic manual rotation if it was known to facilitate normal vaginal births suggesting a scope to introduce this procedure into widespread clinical practice.

An ethnographic organisational study of alongside midwifery units: a follow-on study from the Birthplace in England programme

BackgroundAlongside midwifery units (AMUs) were identified as a novel hybrid organisational form in the Birthplace in England Research Programme, to which this is a follow-on study. The number of such units (also known as hospital birth centres) has increased greatly in the UK since 2007. They provide midwife-led care to low-risk women adjacent to maternity units run by obstetricians, aiming to provide a homely environment to support normal childbirth. Women are transferred to the obstetric unit (OU) if they want an epidural or if complications occur.AimsThis study aimed to investigate the ways that AMUs in England are organised, staffed and managed. It also aimed to look at the experiences of women receiving maternity care in an AMU and the views and experiences of maternity staff, including both those who work in an AMU and those in the adjacent OU.MethodsAn organisational ethnography approach was used, incorporating case studies of four AMUs, selected for maximum variation on the basis of geographical context, length of establishment of an AMU, size of unit, management, leadership and physical design. Interviews were conducted between December 2011 and October 2012 with service managers and key stakeholders (n = 35), with professionals working within and in relation to AMUs (n = 54) and with postnatal women and birth partners (n = 47). Observations were conducted of key decision-making points in the service (n = 20) and relevant service documents and guidelines were collected and reviewed.FindingsWomen and their families valued AMU care highly for its relaxed and comfortable environment, in which they felt cared for and valued, and for its support for normal birth. However, key points of transition for women could pose threats to equity of access and quality of their care, such as information and preparation for AMU care, and gaining admission in labour and transfer out of the unit. Midwives working in AMUs highly valued the environment, approach and the opportunity to exercise greater professional autonomy, but relations between units could also be experienced as problematic and as threats to professional autonomy as well as to quality and safety of care. We identified key themes that pose potential challenges for the quality, safety and sustainability of AMU care: boundary work and management, professional issues, staffing models and relationships, skills and confidence, and information and access for women.ConclusionsAMUs have a role to play in contributing to service quality and safety. They provide care that is satisfying for women, their partners and families and for health professionals, and they facilitate appropriate care pathways and professional roles and skills. There is a potential for AMUs to provide equitable access to midwife-led care when midwifery unit care is the default option (opt-out) for all healthy women. The Birthplace in England study indicated that AMUs provide safe and cost-effective care. However, the opportunity to plan to birth in an AMU is not yet available to all eligible women, and is often an opt-in service, which may limit access. The alignment of physical, philosophical and professional boundaries is inherent in the rationale for AMU provision, but poses challenges for managing the service to ensure key safety features of quality and safety are maintained. We discuss some key issues that may be relevant to managers in seeking to respond to such challenges, including professional education, inter- and intraprofessional communication, relationships and teamwork, integrated models of midwifery and women’s care pathways. Further work is recommended to examine approaches to scaling up of midwifery unit provision, including staffing and support models. Research is also recommended on how to support women effectively in early labour and on provision of evidence-based and supportive information for women.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

A rare complication of vaginal delivery: labial adhesion

Labial adhesions are mostly seen in teenagers and menopausal women, however they may be encountered rarely in the postpartum period. Surgical division under local anesthesia is more effective than topical estrogen. Case: In this article a young women at the age of 23 years, who gave normal vaginal birth 12 months prior and who had difficulty in coitus because of labial sinechia is reported. During physical examination, an adhesion between right and left labia minora approximately three cm in length was observed. The adhesion was seperated under local anesthesia and the patient was discharged from the hospital on the same day. On postoperative seventh day control, she had neither complaints nor complications. Conclusion: Labial adhesions are rarely encountered after normal vaginal childbirth. The most effective treatment of labial sinechia is surgical division under local anesthesia.

Diminished Control and Unmet Expectations: Testing a Model of Adjustment to Unplanned Cesarean Delivery

Compared to vaginal deliveries, surgical (cesarean) deliveries are associated with more complications, longer recovery, lower satisfaction, and greater risk of postpartum mood disturbances. Despite a steep rise in rates of surgical delivery, there have been few theoretically founded investigations of the mechanisms by which delivery method has an effect on psychosocial outcome. We tested a model of adjustment to unplanned cesarean delivery, focusing on two mediators: diminished control over labor and delivery; and unmet expectations of control over childbirth. Participants were 164 women anticipating a normal vaginal childbirth. Women who delivered by unplanned surgical delivery (24% of the sample) experienced significantly lower childbirth satisfaction than women delivering vaginally. As hypothesized, the association of delivery method with childbirth satisfaction was mediated by diminished control and unmet expectations, even after controlling for other predictors. Differences were not found between delivery groups in postpartum depressed mood. Irrespective of delivery method, perceived control during labor and delivery was strongly associated with childbirth satisfaction and lower depressed mood. Findings suggest that enabling women to exert desired control over childbirth is likely to enhance satisfaction and reduce the likelihood of postpartum mood disturbance. Implications for policies relevant to hospitals, employers, insurance companies, and legal practice are discussed.

Demographic factors and determinants of physical activity and breast feeding practices during puerperium in saudi women.

Aim:This cross-sectional study describes the practice of different myths regarding newborns and maternal physical activity among Saudi women during puerperium.Material and Methods:The study was conducted at Mother and Child Hospital, Buraidah from January to December 2011.Results:The multinomial logistic regression (MRA) on age, education, occupation, parity and mode of delivery was statistically significant (χ2 (60) = 487.656, p < .001). Individuals who were between 25 and 30, had education level primary or below, para2 -4 were more likely to limit household activities. Women in the age group of 25-30 were 41 times more likely to have no exercise. Women with parity 2-4 were 24 times more likely to abstain from sex during puerperium as compared to Para 5 and above. Individuals who had a normal vaginal birth were approximately 9 times less likely to be in the kofalaya’s group. Individuals below college level education were more likely to believe that breast feeding in front of others may steal mother’s milk. Women below 25 years of age and women with vaginal delivery were more likely to avoid colostrums feeding. Conclusion:Health Education programs are needed to encourage women to increase physical activity during puerperium and encourage breast feeding. Focus groups for improving physical activity should include age group 25-30 and women with primary and below level education. Women with cesarean delivery should be counseled against kofalayas and women with vaginal delivery should be encouraged for colostrums feeding.

Feasibility and results of at-home follow-up after early postpartum discharge from maternity units in Bobo-Dioulasso, Burkina Faso

to describe the feasibility and results of at-home follow-up of mothers and newborns discharged early from the maternity ward after normal childbirth. This prospective descriptive study took place during a one month period (April 1-30, 2011) in five maternity units in Bobo-Dioulasso, the second largest city in Burkina Faso. Mothers with normal vaginal deliveries and no complications at the sixth hour postpartum were included in the study with their newborns after informed oral consent. The discharge took place between 12 and 48 hours after delivery. The follow-up took place by telephone, home visits, and emergency hospital visits in cases of complications. A postnatal hospital visit was systematically planned for day 7. The study included 630 mothers and their babies. There were 1567 phone calls made: 27 women could not be reached by telephone after discharge, and 140 home visits took place, either at the mother's request or because of the failure to reach her by telephone. Complications were observed in 55 mothers and 135 babies. Postnatal follow-up at home is required for mothers and their newborns discharged early from the maternity ward after normal childbirth in view of the possibility of complications. This ensures continuity of care to improve survival of mothers and babies. As cell phones become more and more available, they may play an important role as a tool for such follow up.

The experience and role of a companion during normal labor and childbirth: a systematic review of qualitative evidence

Review question/objective The objective of this systematic review is to explore experiences and roles of a companion during normal labor and childbirth. Considering the recognized importance of a companion during labor and childbirth, this systematic review was proposed to answer the following questions: a) How the experience of a companion in normal labor and childbirth is lived? b) What role is performed by a companion in normal labor and childbirth? Inclusion criteria Types of participants All adult people (18 years-old or more) who have lived the experience as a companion in labor and/or in childbirth, and that assumed this/these role(s). This systematic review does not restrict the role as a companion to the pregnant women’s spouses. It will be considered as companion any family member, relatives, friends and the pregnant women’ spouses that have lived the experience like a companion. All companions from all cultures will be included. Companions of adolescent and adult pregnant women who have had pregnancy without biological risks will be included. Companions who have shared experiences of miscarriage, abnormal birth, malformation, and prematurity followed by neonatal mortality will not be included. Phenomena of interest This review will consider studies that investigate companion’s experiences and roles played during the normal labor and/or in childbirth. All the normal childbirths will be considered independent of the location of its occurrence (home, clinic, hospital and birth centers). Types of outcomes This review will consider studies that include the following qualitative outcomes: role, social support and life experiences.Role: the expected and characteristic pattern of behavior exhibited by a person as a companion. Social Support: support that provides encouragement to a pregnant woman in order to meet a better coping during the labor. Lived experiences: the experiences lived by a person who concretely has accompanied a pregnant woman during normal labor and/or childbirth.

Medicalisation of childbirth in the occupied Palestinian territory: an operational study

<h3>Background</h3> Almost all births in the occupied Palestinian territory happen in hospitals, and births without complications are assisted by midwives. The application of evidence-based treatment and care during normal childbirth is inadequate. We report changes in practices during normal childbirth through the implementation of interventions aimed at reducing the frequency of intravenous fluid administration, bladder catheterisation, analgesia, artificial rupture of membranes, oxytocin use for augmentation, vaginal examinations, and episiotomy, and increasing mobility, oral intake of fluids, and initiation of immediate breastfeeding. <h3>Methods</h3> We undertook operational research in three phases (baseline [6 months], intervention [18 months], and postintervention [12 months]) in one governmental hospital in the West Bank between 2005 and 2010. We assessed 2345 women—134 in the baseline phase, 1860 in the intervention phase, and 351 in the postintervention phase. During the baseline phase, 2 weeks in 2006, we interviewed all women (mean age 26·1 years [5·8]) after they gave birth but before their discharge from the hospital. In 2007–08, we implemented the interventions, including on-the-job training, auditing, feedback, and meetings with staff. We used a checklist to document the details of care for all pregnant women with singleton pregnancies (n=2146), who went into labour and delivered between 0700 h and 1600 h (when all physicians and consultants are on duty), 2–3 days per week. We excluded 286 women from the analysis because of pre-existing complications, breech, gestational age less than 37 weeks, birth before arrival, and labour during the 3 months of strike in the public health sector. In the postintervention phase (2010), 9 months after the completion of the intervention, we used the same checklist for a sample of 383 women to assess the sustainability of the changes. The changes in practices were tested with χ² and Fisher's exact tests. We analysed data with IBM SPSS Statistics (version 18.0). We obtained permission from the Palestinian Ministry of Health to interview women in the hospital. All women provided verbal informed consent before they were interviewed. <h3>Findings</h3> Improvements from baseline to the postintervention phase were significant (p<0·05) and sustained for seven of ten practices: oxytocin use to augment normal labour (43 [32·1%] of 134 women <i>vs</i> 62 [17·7%] of 351 women; improvement 14·4%), artificial rupture of membranes (98 [73·1%] <i>vs</i> 182 [51·9%]; 21·2%), intravenous fluids (103 [76·9%] <i>vs</i> 97 [27·6%]; 49·3%), oral intake of fluids during labour (five [3·7%] <i>vs</i> 39 [11·1%]; 7·4%), mobility during labour (41 [30·6%] <i>vs</i> 120 [34·2%]; 3·6%), four to seven (65 [48·5%] <i>vs</i> 130 [37·0%]; 11·5%) and eight to 22 vaginal examinations (20 [14·9%] <i>vs</i> 23 [6·6%]; 8·3%), episiotomy for first pregnancy (24 [80·0%] of 30 <i>vs</i> 34 [39·1%] of 87; 40·9%) or second and subsequent pregnancies (six [5·8%] of 104 <i>vs</i> nine [3·4%] of 264; 2·4%), and immediate breastfeeding (77 [57·5%] of 134 <i>vs</i> 328 [93·4%] of 351; 35·9%). The improvements in the mobility and oral intake of fluids during labour were not sustained 9 months after the completion of the intervention phase. The use of analgesia during labour did not change (five [3·7%] <i>vs</i> 13 [3·7%] women). <h3>Interpretation</h3> A limitation of our analysis was the small sample size in the baseline phase. Some changes in the practices during normal childbirth were sustainable during the 9 months after the completion of the intervention. On-the-job training, auditing, and feedback were non-threatening, and a provider-friendly approach enabled integration of evidence into practice with the available resources. In a low-resource setting, supportive supervision, on-the-job training, and regular clinical audit are essential low-cost methods to increase adherence by midwives to the best available evidence and enhance their professional capacities to keep birth normal. <h3>Funding</h3> Theodor-Springmann Foundation, Quota Scheme from Lånekassen, and University of Oslo.

Midwives' and women's views of childbirth in the Gaza Strip, occupied Palestinian territory: an exploratory study

BackgroundIn a quality-of-care assessment of mothers and newborn babies in maternity units in the Gaza Strip, occupied Palestinian territory (oPt), WHO oPt identified poor management of normal childbirth, early discharge, and lack of privacy for women as challenges for the delivery of care to pregnant women. The Palestinian Ministry of Health agreed that these challenges could be addressed by the introduction of a midwifery-led model of care. The aim of this study was to solicit the views of staff and women who had been through childbirth with respect to the introduction of the midwifery-led model of care.MethodsSix focus groups were organised and each group consisted of eight to 12 health professionals (midwives, nurses, or doctors). Selection criteria for the health professionals were experience in midwifery-led model of care and working in a maternity unit of one of the main hospitals in the Gaza Strip. Two focus groups had midwives, two had male and female obstetricians, one had nurse managers, and one had primary health-care midwives and doctors. Three other focus groups were formed with women who had given birth at any time in their lives. Thematic analysis was used to identify themes and subthemes to form the basis for the analysis, and NVivo (version 8) was used to code and emerge themes and subthemes. The Ministry of Health provided the approval to do the study. All participants provided verbal informed consent.FindingsMidwives stated that they lacked training in evidence-based practice. The consensus opinion of the doctors was that normal childbirth is the responsibility of midwives, and they mentioned that the midwives needed training. Managers stated that midwives with a postgraduate education could cope with the increased responsibility, but new graduates needed additional training. Professionals working in primary health care recommended better documentation in the mother–child handbook. Most women said that they preferred women to care for them during childbirth; however, they could not differentiate between midwives and female doctors, and claimed they were not kept well informed about progress and did not have sufficient support during childbirth.InterpretationBefore the midwifery-led model of maternity care can be introduced in the Gaza Strip, midwives need to be given additional training so that they can focus on their core responsibility. The health-care system will assist midwives to respond to these challenges to improve the continuity of care.FundingWHO oPt. In a quality-of-care assessment of mothers and newborn babies in maternity units in the Gaza Strip, occupied Palestinian territory (oPt), WHO oPt identified poor management of normal childbirth, early discharge, and lack of privacy for women as challenges for the delivery of care to pregnant women. The Palestinian Ministry of Health agreed that these challenges could be addressed by the introduction of a midwifery-led model of care. The aim of this study was to solicit the views of staff and women who had been through childbirth with respect to the introduction of the midwifery-led model of care. Six focus groups were organised and each group consisted of eight to 12 health professionals (midwives, nurses, or doctors). Selection criteria for the health professionals were experience in midwifery-led model of care and working in a maternity unit of one of the main hospitals in the Gaza Strip. Two focus groups had midwives, two had male and female obstetricians, one had nurse managers, and one had primary health-care midwives and doctors. Three other focus groups were formed with women who had given birth at any time in their lives. Thematic analysis was used to identify themes and subthemes to form the basis for the analysis, and NVivo (version 8) was used to code and emerge themes and subthemes. The Ministry of Health provided the approval to do the study. All participants provided verbal informed consent. Midwives stated that they lacked training in evidence-based practice. The consensus opinion of the doctors was that normal childbirth is the responsibility of midwives, and they mentioned that the midwives needed training. Managers stated that midwives with a postgraduate education could cope with the increased responsibility, but new graduates needed additional training. Professionals working in primary health care recommended better documentation in the mother–child handbook. Most women said that they preferred women to care for them during childbirth; however, they could not differentiate between midwives and female doctors, and claimed they were not kept well informed about progress and did not have sufficient support during childbirth. Before the midwifery-led model of maternity care can be introduced in the Gaza Strip, midwives need to be given additional training so that they can focus on their core responsibility. The health-care system will assist midwives to respond to these challenges to improve the continuity of care.

Expectativas, percepções e experiências sobre o parto normal: relato de um grupo de mulheres

Este artigo mostra os resultados de um estudo realizado com 25 gestantes entre 16 e 34 anos e duas puérperas. O objetivo foi conhecer as percepções, experiências e expectativas em relação ao parto normal, além de saber qual tipo de informação elas dispunham sobre a parturição, puerpério e o direito de ter um acompanhante no parto. Foram adotadas as técnicas da entrevista livre e da observação participante. Os dados coletados foram analisados à luz da Análise do Discurso. As mulheres entrevistadas demonstraram maior preferência pelo parto normal. A maioria das informações ou orientações recebidas pelos profissionais de saúde, restringiu-se à dimensão física da dor e primeiros cuidados com o nascituro, em detrimento da dimensão psicológica e emocional, relegando-as à uma posição passiva, o que não as impediu de serem críticas frente às orientações recebidas, o que sugere que, humanizar implica também respeitar a necessidade e singularidade de cada mulher.

Does the use of modern family planning promote healthy timing and spacing of pregnancy in Dar es Salaam?

BackgroundTiming, spacing and limiting of pregnancy are key outcomes of family planning (FP) whose role in promoting health of mothers and babies is evidence based. Despite the evidence, recent studies in Tanzania have reported a trend towards child birth in older age, non-adherence to standard inter-pregnancy spacing, and preference of large families in the background of a rising national contraceptive prevalence rate. We explored if the use of modern FP promotes healthy timing and spacing of pregnancy among women seeking antenatal services.DesignAnalytical Cross-sectional studyMethodsWomen seeking antenatal services at Muhimbili National Hospital, Tanzania (August-October, 2012) were enrolled. We used a semi-structured questionnaire to obtained information from the women. Data were analyzed using SPSS version 19. Outcomes of interest were adherence to timing of first pregnancy and to inter-pregnancy spacing after normal childbirth. Use of modern FP prior to index pregnancy was the independent variable of primary interest. Bivariate and multivariate logistic regression analyses were conducted to obtain odds ratios (OR) and 95% confidence intervals (CI) as estimates risk and clinical importance respectively. Ethical approval was obtained from the Research and Publications Committee at Muhimbili University of Health and Allied Sciences.ResultsIn total 427 women were interviewed. Ages ranged 15–45 years, mean 29.2 (SD ± 5.1). Among all, 129 (30.2%) were primigravida, 298 (69. 8%) multigravida. Of these 298 women, 51 (17.1%) lost pregnancies preceding the index. Overall, 179 (41.9%) had ever used modern FP, 103 (24.1%) were on modern FP just prior to index pregnancy.Non-adherence to timing was increased for primigravida (AOR = 4.5, 95% CI: 2.1-9.6) and for women older than 29 years (AOR = 7.6 95% CI: 3.8-15.2). Non-adherence to spacing was increased with loss of the immediate past pregnancy (AOR = 2.5; 95% CI: 1.3-4.7). Use of modern FP was neither associated with adherence to timing (AOR = 1.0; 95% CI: 0.5-1.9) nor spacing (AOR = 1.0; 95% CI: 0.6-1.8).ConclusionModern FP does not promote adherence to timing and spacing of pregnancy among women seeking antenatal services at MNH. Past obstetric experience was key to women’s decisions on spacing. There is need to promote educational messages on timing and spacing of pregnancy for healthy outcomes.

Use of alternative and complementary therapies in labor and delivery care: a cross-sectional study of midwives' training in Catalan hospitals accredited as centers for normal birth.

BackgroundThe use of complementary and alternative medicine (CAM) and complementary and alternative therapies (CAT) during pregnancy is increasing. Scientific evidence for CAM and CAT in the field of obstetrics mainly covers pain relief in labor. Midwives are responsible for labor and delivery care: hence, their knowledge of CAM and CAT is important. The aims of this study are to describe the professional profile of midwives who provide care for natural childbirth in Catalan hospitals accredited as centers for normal birth, to assess midwives’ level of training in CAT and their use of these therapies, and to identify specific resources for CAT in labor wards.MethodsA descriptive, cross-sectional, quantitative method was used to assess the level of training and use of CAT by midwives working at 28 hospitals in Catalonia, Spain, accredited as public normal birth centers.ResultsJust under a third of midwives (30.4%) trained in CAT after completion of basic training. They trained in an average of 5.97 therapies (SD 3.56). The number of CAT in which the midwives were trained correlated negatively with age (r = - 0.284; p < 0.001) and with their time working at the hospital in years (r = - 0.136; p = 0.036). Midwives trained in CAT considered that the following therapies were useful or very useful for pain relief during labor and delivery: relaxation techniques (64.3%), hydrotherapy (84.8%) and the application of compresses to the perineum (75.9%). The availability of resources for providing CAT during normal birth care varied widely from center to center.ConclusionsAge may influence attitudes towards training. It is important to increase the number of midwives trained in CAM for pain relief during childbirth, in order to promote the use of CAT and ensure efficiency and safety. CAT resources at accredited hospitals providing normal childbirth care should also be standardized.

A study to promote breast feeding in the Helsinki Metropolitan area in Finland

Objectivethe aim of this study was to assess the impact of providing intensified support for breast feeding during the perinatal period. Designa quasi-experimental design with non-equivalent control group. Settingthree public maternity hospitals (two study, one control) in the Helsinki Metropolitan area in Finland. Participantsa convenience sample of 705 mothers (431 in the intervention group, 274 in the control group). Methods and interventionin this study, families in the intervention group had access to intensified breast feeding support from midpregnancy, whereas those in the control group had access to normal care. Intensified support included lectures and workshops to health professionals, and families in the intervention group had access to more intensive support and counselling for breast feeding and a breast feeding outpatient clinic. Additionally, an internet-based intervention was only used in the intervention group, but not in the control group. Mothers in the control group received normal care from the midwifery and nursing professionals who were to continue their work normally. The data were analysed statistically. Findingsaltogether 705 women participated in the study. In the intervention group (n=431), 76% of the women breast fed exclusively throughout the hospital stay, compared to 66% of the mothers in the control group (n=274). In multivariate analysis, the likelihood of exclusive breast feeding at the time of responding (at hospital discharge or after that at home) was increased by the mother not being treated for an underlying illness or medical problem during pregnancy, being in the intervention group, having normal vaginal childbirth, high breast feeding confidence, positive attitude towards breast feeding, good coping with breast feeding, and 24-hour presence of the infant's father in the ward. Key conclusions and implications for practicethe low exclusive breast feeding rates of newborns could be increased by using intensified breast feeding support. Mothers' health problems during pregnancy can decrease exclusive breast feeding.Mothers with health problems or other than normal childbirth should receive extra breast feeding support, and the presence of fathers in the ward should be encouraged.Intensified breast feeding counselling and support helps mothers to breast feed exclusively. This support should be available in a variety of forms, so that mothers can choose the type of support they need. As breast feeding counselling and support is intensified, more mothers succeed with exclusive breast feeding.

Driving 933km to have a calm, upright, normal vaginal breech birth

Driving 933km to have a calm, upright, normal vaginal breech birth

Birthing in the Barkly: births to Barkly women in 2010

A 2007 review of maternity services in Australia's Northern Territory (NT) noted the dissatisfaction of women in the Barkly region where the birthing service closed in 2006. The review recommended improved integration of maternity services, a consumer focus, and a pilot study of birthing in Tennant Creek Hospital (TCH) in the Barkly region. Barkly region is sparsely populated, with 5700 people in 320,000 km². The town of Tennant Creek with 3100 population is the only centre of more than 1000 people. In the Barkly region, 64% of the population and 74% of birthing women are Aboriginal. Current NT Department of Health (NT DoH) policy requires all women to give birth in a town with facilities for operative delivery. For most Barkly women this means travelling 500 km to Alice Springs with limited support for travel and accommodation. Emergency air evacuation is arranged for all women who enter labour or give birth while in the Barkly region, whether at TCH or elsewhere. This project was a collaboration between Anyinginyi Health Aboriginal Corporation and NT DoH to examine clinical data to inform a discussion of re-introducing birthing to TCH. Women who were resident in the Barkly region and gave birth in NT in 2010 were identified from the NT Midwives Data Collection. Women who gave birth in Central Australia were managed at Alice Springs Hospital (ASH), either for the birth or afterwards. Antenatal, birthing, postnatal and neonatal data were extracted from ASH records. In total 99 women were identified as residents in the Barkly region from all those who gave birth in 2010. Of these, 83 gave birth in Central Australia, and their records were reviewed for this study, showing that 69 (83%) were Aboriginal; 42 were resident in Tennant Creek; and 29% were aged under 20 years with one under 16 years. Regarding delivery, 53 (64%) women had an unassisted vaginal birth; of 18 women who had had a previous caesarean section, 5 (28%) had a vaginal birth; of the 25 women who had had a normal vaginal birth previously and had no indications for obstetric consultation at the time of labour, three underwent emergency caesarean section. There were 86 infants, all liveborn; 16% were preterm; 21% were of low birth weight; and 6% weighed more than 4.5 kg. Six women gave birth in the Barkly region, two at TCH and four in health centres in remote townships. These mothers and babies were evacuated immediately following birth to ASH, irrespective of indications for referral. Eleven women were evacuated to ASH in labour and six of these were preterm. Opportunities exist to improve maternity care through improved collaboration, even when women cannot give birth in or near their home community due to the absence of birthing services. The remote location of the Barkly region presents challenges to providing maternity care that addresses medical, cultural, psychological and social needs of the childbearing population. Because of this, every opportunity should be taken to optimise maternity care by improvements in continuity of care and carer, improved communication between service providers, and the use of evidence-based guidelines.

In Cyprus, ‘midwifery is dying…’. A qualitative exploration of midwives' perceptions of their role as advocates for normal childbirth

Backgroundadvocacy has been identified as vital for improving maternal and newborn health. In many countries, midwives struggle to advocate for women; in Cyprus, there has been no research into perceptions of advocacy amongst midwives. Aimthis study provides an exploration of the perceptions of midwives as client advocates for normal childbirth in Cyprus. Designa qualitative approach was adopted, using participant observation and semi-structured interviews with a purposive sample of twenty experienced midwives. A thematic approach was taken for the analysis. Findingsfive main interconnected themes emerged, two of which, ‘Lack of professional recognition’ and ‘Deficiencies in basic or continuing education’ presented barriers to midwives' adoption of an advocacy role. Three themes reflected structural factors that also discouraged midwives from acting as advocates: these were ‘physician dominance’, ‘medicalisation of childbirth’ and ‘lack of institutional support’. Conclusionadvocacy is a demanding and challenging role and midwives should be empowered to feel confident in undertaking this role through continuing professional education programmes and professional recognition. In order to be effective advocates, midwives needed to be recognised and valued by the public and by other health professionals as equal partners within the multidisciplinary team. However, midwives in Cyprus find themselves in difficult situations when advocating normal childbirth due to medical domination of the health services, medicalisation of childbirth and inadequate institutional support. Implications for practicein this setting, midwives need to gain professional recognition, to have more effective basic and continuing education programmes and receive better support from managers and policy makers in order to become advocates for normal childbirth.