Background: Post-term pregnancy, a pregnancy exceeding 294 days or 42 completed weeks, is associated with increased perinatal morbidity and mortality and is considered a high-risk condition which requires specialist surveillance and induction of labour. However, there is uncertainty on the policy concerning the timing of induction for post-term pregnancy or impending post-term pregnancy, leading to practice variation between caregivers. Previous studies on induction at or beyond 41 weeks versus expectant management showed different results on perinatal outcome though conclusions in meta-analyses show a preference for induction at 41 weeks. However, interpretation of the results is hampered by the limited sample size of most trials and the heterogeneity in design. Most control groups had a policy of awaiting spontaneous onset of labour that went far beyond 42 weeks, which does not reflect usual care in The Netherlands where induction of labour at 42 weeks is the regular policy. Thus leaving the question unanswered if induction at 41 weeks results in better perinatal outcomes than expectant management until 42 weeks. Methods/design: In this study we compare a policy of labour induction at 41 + 0/+1 weeks with a policy of expectant management until 42 weeks in obstetrical low risk women without contra-indications for expectant management until 42 weeks and a singleton pregnancy in cephalic position. We will perform a multicenter randomised controlled clinical trial. Our primary outcome will be a composite outcome of perinatal mortality and neonatal morbidity. Secondary outcomes will be maternal outcomes as mode of delivery (operative vaginal delivery and Caesarean section), need for analgesia and postpartum haemorrhage (≥1000 ml). Maternal preferences, satisfaction, wellbeing, pain and anxiety will be assessed alongside the trial. Discussion: his study will provide evidence for the management of pregnant women reaching a gestational age of 41 weeks.
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Background: In 2009, the Steering Committee for Pregnancy and Childbirth in the Netherlands recommended the implementation of continuous care during labor in order to improve perinatal outcomes. However, in current care, routine maternity caregivers are unable to provide this type of care, resulting in an implementation rate of less than 30%. Maternity care assistants (MCAs), who already play a nursing role in low risk births in the second stage of labor and in homecare during the postnatal period, might be able to fill this gap. In this study, we aim to explore the (cost) effectiveness of adding MCAs to routine first- and second-line maternity care, with the idea that these MCAs would offer continuous care to women during labor. Methods: A randomized controlled trial (RCT) will be performed comparing continuous care (CC) with care-as-usual (CAU). All women intending to have a vaginal birth, who have an understanding of the Dutch language and are > 18 years of age, will be eligible for inclusion. The intervention consists of the provision of continuous care by a trained MCA from the moment the supervising maternity caregiver establishes that labor has started. The primary outcome will be use of epidural analgesia (EA). Our secondary outcomes will be referrals from primary care to secondary care, caesarean delivery, instrumental delivery, adverse outcomes associated with epidural (fever, augmentation of labor, prolonged labor, postpartum hemorrhage, duration of postpartum stay in hospital for mother and/or newborn), women’s satisfaction with the birth experience, cost-effectiveness, and a budget impact analysis. Cost effectiveness will be calculated by QALY per prevented EA based on the utility index from the EQ-5D and the usage of healthcare services. A standardized sensitivity analysis will be carried out to quantify the outcome in addition to a budget impact analysis. In order to show a reduction from 25 to 17% in the primary outcome (alpha 0.05 and bèta 0.20), taking into account an extra 10% sample size for multi-level analysis and an attrition rate of 10%, 2 × 496 women will be needed (n = 992). Discussion: We expect that adding MCAs to the routine maternity care team will result in a decrease in the use of epidural analgesia and subsequent costs without a reduction in patient satisfaction. It will therefore be a costeffective intervention. Trial registration: Trial Registration: Netherlands Trial Register, NL8065. Registered 3 October 2019 - Retrospectively registered.
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Background: The maternity care system in the Netherlands is well known for its support of community-based midwifery. However, regular midwifery practices typically do not offer caseload midwifery care – one-to-one continuity of care throughout pregnancy and birth. Because we know very little about the outcomes for women receiving caseload care in the Netherlands, we compared caseload care with regular midwife-led care, looking at maternal and perinatal outcomes, including antenatal and intrapartum referrals to secondary (i.e., obstetrician-led) care. Methods: We selected 657 women in caseload care and 1954 matched controls (women in regular midwife-led care) from all women registered in the Dutch Perinatal Registry (Perined) who gave birth in 2015. To be eligible for selection the women had to be in midwife-led antenatal care beyond 28 gestational weeks. Each woman in caseload care was matched with three women in regular midwife-led care, using parity, maternal age, background (Dutch or non-Dutch) and region. These two cohorts were compared for referral rates, mode of birth, and other maternal and perinatal outcomes. Results: In caseload midwifery care, 46.9% of women were referred to obstetrician-led care (24.2% antenatally and 22.8% in the intrapartum period). In the matched cohort, 65.7% were referred (37.4% antenatally and 28.3% in the intrapartum period). In caseload care, 84.0% experienced a spontaneous vaginal birth versus 77.0% in regular midwife-led care. These patterns were observed for both nulliparous and multiparous women. Women in caseload care had fewer inductions of labour (13.2% vs 21.0%), more homebirths (39.4% vs 16.1%) and less perineal damage (intact perineum: 41.3% vs 28.2%). The incidence of perinatal mortality and a low Apgar score was low in both groups. Conclusions: We found that when compared to regular midwife-led care, caseload midwifery care in the Netherlands is associated with a lower referral rate to obstetrician-led care – both antenatally and in the intrapartum period – and a higher spontaneous vaginal birth rate, with similar perinatal safety. The challenge is to include this model as part of the current effort to improve the quality of Dutch maternity care, making caseload care available and affordable for more women.
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Background: The most common reason for caesarean section (CS) is repeat CS following previous CS. Vaginal birth after caesarean section (VBAC) rates vary widely in different healthcare settings and countries. Obtaining deeper knowledge of clinicians’ views on VBAC can help in understanding the factors of importance for increasing VBAC rates. Interview studies with clinicians and women in three countries with high VBAC rates (Finland, Sweden and the Netherlands) and three countries with low VBAC rates (Ireland, Italy and Germany) are part of ‘OptiBIRTH’, an ongoing research project. The study reported here is based on interviews in high VBAC countries. The aim of the study was to investigate the views of clinicians working in countries with high VBAC rates on factors of importance for improving VBAC rates. Methods: Individual (face-to-face or telephone) interviews and focus group interviews with clinicians (in different maternity care settings) in three countries with high VBAC rates were conducted during 2012–2013. In total, 44 clinicians participated: 26 midwives and 18 obstetricians. Five central questions about VBAC were used and interviews were analysed using content analysis. The analysis was performed in each country in the native language and then translated into English. All data were then analysed together and final categories were validated in each country. Results: The findings are presented in four main categories with subcategories. First, a common approach is needed, including: feeling confident with VBAC, considering VBAC as the first alternative, communicating well, working in a team, working in accordance with a model and making agreements with the woman. Second, obstetricians need to make the final decision on the mode of delivery while involving women in counselling towards VBAC. Third, a woman who has a previous CS has a similar need for support as other labouring women, but with some extra precautions and additional recommendations for her care. Finally, clinicians should help strengthen women’s trust in VBAC, including building their trust in giving birth vaginally, recognising that giving birth naturally is an empowering experience for women, alleviating fear and offering extra visits to discuss the previous CS, and joining with the woman in a dialogue while leaving the decision about the mode of birth open. Conclusions: This study shows that, according to midwives and obstetricians from countries with high VBAC rates, the important factors for improving the VBAC rate are related to the structure of the maternity care system in the country, to the cooperation between midwives and obstetricians, and to the care offered during pregnancy and birth. More research on clinicians’ perspectives is needed from countries with low, as well as high, VBAC rates.
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The unexpected death of a child is one of the most challenging losses as it fractures survivors’ sense of parenthood and other layers of identity. Given that not all the bereaved parents who have need for support respond well to available treatments and that many have little access to further intervention or follow-up over time, online interventions featuring therapeutic writing and peer support have strong potential. In this article we explore how a group of bereaved mothers experienced the process of participating in an online course in therapeutic writing for the integration of grief. Our research questions were: How do parents who have lost a child experience being part of an online course in therapeutic writing? What are the perceived benefits and challenges of writing in processing their grief? We followed an existential phenomenological approach and analyzed fieldwork notes (n = 13), qualitative data from the application and assessment surveys (n = 35; n = 21), excerpts from the journals of some participants (n = 3), and email correspondence with some participants (n = 5). We categorized the results in three meaning units: (1) where does my story begin? The “both and” of their silent chaos; (2) standing on the middle line: a pregnancy that does not end; (3) closures and openings: “careful optimism” and the need for community support. Participants experienced writing as an opportunity for self-exploration regarding their identities and their emotional world, as well as a means to develop and strengthen a bond with their children. They also experienced a sense of belonging, validation, and acceptance in the online group in a way that helped them make sense of their suffering. Online writing courses could be of benefit for bereaved parents who are grieving the unexpected death of a child, but do not replace other interventions such as psychotherapy. In addition to trauma and attachment informed models of grief, identity informed models with a developmental focus might enhance the impact of both low-threshold community interventions and more intensive clinical ones. Further studies and theoretical development in the area are needed, addressing dialogical notions such as the multivoicedness of the self. Lehmann OV, Neimeyer RA, Thimm J, Hjeltnes A, Lengelle R and Kalstad TG (2022) Experiences of Norwegian Mothers Attending an Online Course of Therapeutic Writing Following the Unexpected Death of a Child. Front. Psychol. 12:809848. doi: 10.3389/fpsyg.2021.809848
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Kinderen met een lage sociaaleconomische status (SES) hebben een verhoogd risico op een suboptimale start in het leven met hogere kosten voor de gezondheidszorg. Deze studie onderzoekt de effecten van SES op individueel (maandelijks huishoudinkomen) en contextuele SES (huishoudinkomen en buurtdeprivatie), en perinatale morbiditeit op de zorgkosten in het vroege leven (0-3 jaar). Conclusie: Meer buurtdeprivatie was direct gerelateerd aan hogere zorgkosten bij jonge kinderen. Bovendien was een lager huishoudinkomen consistent en onafhankelijk gerelateerd aan hogere zorgkosten. Door de omstandigheden voor lage SES-populaties te optimaliseren, kan de impact van lage SES-omstandigheden op hun zorgkosten positief worden beïnvloed.
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1 Maternity services across Europe during the pandemic has undergone changes to limit virus transmission; however, many changes are not evidence-based. 2 Although these changes were introduced to keep women, babies and healthcare staff safe, the exclusion of companions and the separation of mothers and babies is particularly antithetical to a human rights-based approach to quality care. 3 A poll of COST Action 18211 network members showed that inconsistency in the application of restrictions was high, and there were significant deviations from the recommendations of authoritative bodies. 4 Concerns have emerged that restrictions in practice may have longer term negative impacts on mothers and their families and, in particular, may impact on the long-term health of babies. 5 When practice changes deviate from evidence-based frameworks that underpin quality care, they must be monitored, appraised and evaluated to minimise unintended iatrogenic effects.
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Zorgcapaciteit kan een belangrijke schakel zijn tussen multi-probleem omstandigheden en ongunstige ontwikkeling van kinderen. Deze studie heeft als doel om de zorgcapaciteit en de correlaties daartussen te onderzoeken in zeer kwetsbare multiprobleemgezinnen in Rotterdam, Nederland. Zorgcapaciteit (algemeen, emotioneel en instrumenteel) werd prospectief beoordeeld bij 83 zeer kwetsbare vrouwen met behulp van video-observaties van dagelijkse zorgtaken, zes weken postpartum. Ondersteunende gegevens werden verzameld op drie tijdstippen: bij inclusie, zes weken na inclusie en zes weken postpartum, en deze omvatten psychologische symptomen, zelfredzaamheid, problematische levensdomeinen, thuisomgeving, inkomen, depressie, angst en stress. Zwangerschaps- en bevallingsgerelateerde informatie werd verzameld bij verloskundigen. De scores voor zorgverlening door de moeder waren gemiddeld van onvoldoende kwaliteit. Moeders die in een onveilige thuisomgeving leefden (B = 0,62) en moeders met meer problematische levensdomeinen (≤3 domeinen, B = 0,32) vertoonden significant hogere instrumentele zorgcapaciteiten. Andere variabelen waren niet gerelateerd aan zorgcapaciteit. De zorgcapaciteit in deze zeer kwetsbare populatie was van onvoldoende kwaliteit. In de meeste gevallen was er echter geen significant verband tussen zorgzaamheid en de variabelen die gerelateerd zijn aan kwetsbaarheid. Dit betekent dat een mogelijk verband tussen kwetsbaarheid en zorgcapaciteit kan worden veroorzaakt door de interactie tussen verschillende problemen, in plaats van door het type of de omvang van de zorg.
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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.
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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.
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