Background Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. Methods In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations. Findings Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. Conclusions Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.
DOCUMENT
Background: Empowerment is expected to have a beneficial effect on a woman’s well-being during the perinatal period and her readiness to face the challenges of motherhood. In the literature on pregnancy and childbirth, empowerment is used widely in different contexts, with different connotations and often without a definition, thus indicating a lack of clarity of what is actually meant by the concept. Objective: To report an analysis of the concept of women’s empowerment in the context of the perinatal period. Methods: We used the concept analysis framework of Walker and Avant to analyse the concept of women’s empowerment during pregnancy and childbirth. In July 2018, we did a systematic search in EBSCOhost, including the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX, using keywords: empower, women, childbirth and their synonyms. All selected papers were analysed for definitions of empowerment, defining attributes, antecedents and consequences. Results: Ninety-seven scientific papers from all continents were included in the analysis. Defining attributes, antecedents, consequences and empirical referents are discussed, and a model case as well as related and contrary cases are presented. Conclusion: Attributes, external and internal to the woman, were identified. Both types of attributes need to be considered within the broader socio-cultural-economic-political landscape of the individual woman, in conjunction with a woman’s belief in herself and her meaningful interconnectedness with carers. Relevance: This study resulted in an understanding of empowerment in the context of pregnancy and childbirth that can be used in research and for the development of interventions preparing women for childbirth and their subsequent transition to motherhood.
DOCUMENT
Objective To synthesise qualitative studies on women’s psychological experiences of physiological childbirth. Design Meta-synthesis. Methods Studies exploring women’s psychological experiences of physiological birth using qualitative methods were eligible. The research group searched the following databases: MEDLINE, CINAHL, PsycINFO, PsycARTICLES, SocINDEX and Psychology and Behavioural Sciences Collection. We contacted the key authors searched reference lists of the collected articles. Quality assessment was done independently using the Critical Appraisal Skills Programme (CASP) checklist. Studies were synthesised using techniques of meta-ethnography. Results Eight studies involving 94 women were included. Three third order interpretations were identified: ‘maintaining self-confidence in early labour’, ‘withdrawing within as labour intensifies’ and ‘the uniqueness of the birth experience’. Using the first, second and third order interpretations, a line of argument developed that demonstrated ‘the empowering journey of giving birth’ encompassing the various emotions, thoughts and behaviours that women experience during birth. Conclusion Giving birth physiologically is an intense and transformative psychological experience that generates a sense of empowerment. The benefits of this process can be maximised through physical, emotional and social support for women, enhancing their belief in their ability to birth and not disturbing physiology unless it is necessary. Healthcare professionals need to take cognisance of the empowering effects of the psychological experience of physiological childbirth. Further research to validate the results from this study is necessary.
DOCUMENT
Background: In order to internalize the midwifery philosophy of care and to learn how to advocate for physiological childbirth, student midwives in the Netherlands need learning experiences that expose them to physiological childbirth practices. Increased hospital births, wide variation in non-urgent referrals and escalating interventions impact on learning opportunities for physiological childbirth. Midwifery educators need to find ways to support student agency in becoming advocates of physiological childbirth. Objective: To gather students’ opinions of what they need to become advocates of physiological childbirth. Methods: Focus groups with student midwives (n = 37), examining attitudes regarding what educational programs must do to support physiological childbirth advocacy. Results: Students reported feelings of personal power when the midwifery philosophy of care is internalized and expressed in practice. Students also identified dilemmas associated with supporting woman-centered care and promoting physiological childbirth. Perceived hierarchy in clinical settings causes difficulties, leading students to practice in accordance with the norms of midwife preceptors. Students are supported in the internalization and realization of the midwifery philosophy of care, including physiological childbirth, if they are exposed to positive examples of care in practice and have opportunities to discuss and reflect on these in the classroom. Key conclusion: Midwifery education should focus on strategies that include navigating dilemmas in practice and helping students to express the midwifery philosophy of care in communication with other professionals and with women. Preceptors need to be supported in allowing student midwives opportunities to realize the midwifery philosophy of care, also when this differs from preceptor practice.
DOCUMENT
Background Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial role of one-to-one support during labor and birth. The physiological importance of social support to reduce labor stress and pain necessitates a reconsideration of many aspects of modern maternity care. Conclusion By listening to women’s experiences and by observing women during childbirth, factors that contribute to an optimized process of labor, such as the mothers’ wellbeing and feelings of safety, may be identified. These observations support the integrative role of endogenous oxytocin in coordinating the neuroendocrine, psychological and physiological aspects of labor and birth, including oxytocin mediated. decrease of pain, fear and stress, support the need for midwifery one-to-one support in labour as well as the need for maternity care that optimizes the function of these neuroendocrine processes even when birth interventions are used. Women and their partners would benefit from understanding the crucial role that endogenous oxytocin plays in the psychological and neuroendocrinological process of labor.
DOCUMENT
Introduction: Midwifery education that strengthens self-efficacy can support student midwives in their role as advocates for a physiological approach to childbirth. Methods: To assess the effect of an educational intervention on self-efficacy, a pre- and post-intervention survey was administered to a control group and an intervention group of third year student midwives. The General Self-Efficacy Scale (GSES) was supplemented with midwifery-related self-efficacy questions related to behaviour in home and hospital settings, the communication of evidence, and ability to challenge practice. Results: Student midwives exposed to midwifery education designed to strengthen self-efficacy demonstrated significantly higher levels of general self-efficacy (p = .001) when contrasted to a control cohort. These students also showed significantly higher levels of self-efficacy in advocating for physiological childbirth (p = .029). There was a non-significant increase in self-efficacy in the hospital setting in the intervention group, a finding that suggests that education may ameliorate the effect of hospital settings on midwifery practice. Discussion: In spite of the small size of the study population, education that focuses on strengthening student midwife self-efficacy shows promise.
DOCUMENT
Despite the consequences for women’s health, a repeat cesarean section (CS) birth after a previous CS is common in Western countries. Vaginal Birth After Cesarean (VBAC) is recommended for most women, yet VBAC rates are decreasing and vary across maternity organizations and countries. We investigated women’s views on factors of importance for improving the rate of VBAC in countries where VBAC rates are high. We interviewed 22 women who had experienced VBAC in Finland, the Netherlands, and Sweden. We used content analysis, which revealed five categories: receiving information from supportive clinicians, receiving professional support from a calm and confident midwife/obstetrician during childbirth, knowing the advantages of VBAC, letting go of the previous childbirth in preparation for the new birth, and viewing VBAC as the first alternative for all involved when no complications are present. These findings reflect not only women’s needs but also sociocultural factors influencing their views on VBAC.
MULTIFILE
Background The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. Methods The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates. Results 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. Conclusions This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only.
MULTIFILE
Background: The dynamics of maternal and newborn care challenge midwifery education programs to keep up-to-date. To prepare for their professional role in a changing world, role models are important agents for student learning. Objective: To explore the ways in which Dutch and Icelandic midwifery students identify role models in contemporary midwifery education. Methods: We conducted a descriptive, qualitative study between August 2017 and October 2018. In the Netherlands, 27 students participated in four focus groups and a further eight in individual interviews. In Iceland, five students participated in one focus group and a further four in individual interviews. All students had clinical experience in primary care and hospital. Data were analyzed using inductive content analysis. Results: During their education, midwifery students identify people with attitudes and behaviors they appreciate. Students assimilate these attitudes and behaviors into a role model that represents their ‘ideal midwife’, who they can aspire to during their education. Positive role models portrayed woman-centered care, while students identified that negative role models displayed behaviors not fitting with good care. Students emphasized that they learnt not only by doing, they found storytelling and observing important aspects of role modelling. Students acknowledged the impact of positive midwifery role models on their trust in physiological childbirth and future style of practice. Conclusion: Role models contribute to the development of students’ skills, attitudes, behaviors, identity as midwife and trust in physiological childbirth. More explicit and critical attention to how and what students learn from role models can enrich the education program.
DOCUMENT
Introduction This study aims to explore maternal and perinatal outcomes of migrant women in Iceland. Material and methods This prospective population-based cohort study included women who gave birth to a singleton in Iceland between 1997 and 2018, comprising a total of 92 403 births. Migrant women were defined as women with citizenship other than Icelandic, including refugees and asylum seekers, and categorized into three groups, based on their country of citizenship Human Development Index score. The effect of country of citizenship was estimated. The main outcome measures were onset of labor, augmentation, epidural, perineum support, episiotomy, mode of birth, obstetric anal sphincter injury, postpartum hemorrhage, preterm birth, a 5-minute Apgar <7, neonatal intensive care unit admission and perinatal mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) for maternal and perinatal outcomes were calculated using logistic regression models. Results A total of 8158 migrant women gave birth during the study period: 4401 primiparous and 3757 multiparous. Overall, migrant women had higher adjusted ORs (aORs) for episiotomy (primiparas: aOR 1.43, 95% CI 1.26–1.61; multiparas: 1.39, 95% CI 1.21–1.60) and instrumental births (primiparas: 1.14, 95% CI 1.02–1.27, multiparas: 1.41, 95% CI 1.16–1.72) and lower aORs of induction of labor (primiparas: 0.88, 95% CI 0.79–0.98; multiparas: 0.74, 95% CI 0.66–0.83), compared with Icelandic women. Migrant women from countries with a high Human Development Index score (≥0.900) had similar or better outcomes compared with Icelandic women, whereas migrant women from countries with a lower Human Development Index score than that of Iceland (<0.900) had additionally increased odds of maternal and perinatal complications and interventions, such as emergency cesarean and postpartum hemorrhage. Conclusions Women’s citizenship and country of citizenship Human Development Index scores are significantly associated with a range of maternal and perinatal complications and interventions, such as episiotomy and instrumental birth. The results indicate the need for further exploration of whether Icelandic perinatal healthcare services meet the care needs of migrant women.
DOCUMENT
