Abstract: OBJECTIVE: to explore the experiences and concerns of health professionals who care for childbearing women who are obese. BACKGROUND: obesity is increasing nationally and internationally and has been described as an epidemic. A number of studies have highlighted the risks associated with obesity during childbirth, yet few studies have investigated the experiences and concerns of midwives and other health professionals in providing care to these women. DESIGN: a descriptive qualitative study using focus groups and face-to-face interviews to collect data. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis. SETTING: three maternity units in New South Wales, Australia. PARTICIPANTS: participants included 34 midwives and three other health professionals. FINDINGS: three major themes emerged from the data analysis: 'a creeping normality', 'feeling in the dark' and 'the runaway train'. The findings highlight a number of tensions or contradictions experienced by health professionals when caring for childbearing women who are obese. These include, on the one hand, an increasing acceptance of obesity ('a creeping normality'), and on the other, the continuing stigma associated with obesity; the challenges of how to communicate effectively with pregnant women about their weight and the lack of resources, equipment and facilities ('feeling in the dark') to adequately care for obese childbearing women. Participants expressed concerns about how quickly the obesity epidemic appears to have impacted on maternity services ('the runaway train') and how services to meet the needs of these women are limited or generally not available. CONCLUSION AND IMPLICATIONS FOR PRACTICE: it was clear in this study that participants felt that they were 'not waving but drowning'. There was concern over the fact that the issue of obesity had moved faster than the health response to it. There were also concerns about how to communicate with obese women without altering the relationship. Continuity of care, training and skills development for health professionals, and expansion of limited services and facilities for these women are urgently needed.
Abstract: BACKGROUND: There is a belief amongst midwives that Asian women are less likely to breastfeed compared to non-Asian women. The aim of this research was to compare the infant feeding decisions of Asian and non-Asian women on discharge from two Sydney hospitals, and at 6 and 12 weeks following birth. PARTICIPANTS: 235 Asian and 462 non-Asian first time mothers. METHODS: A secondary analysis was undertaken into data from a randomised clinical trial of a perineal management technique (perineal warm packs). Simple descriptive statistics were used for analysis and Chi-square and logistic regression was used to examine differences between women from Asian and non-Asian backgrounds. RESULTS: Compared with non-Asian women, Asian women were no less likely to exclusively breastfeed on discharge from hospital (83% vs. 87%, OR 0.7, 95% CI 0.4-1.2), at 6 weeks (60% vs. 61%, OR 1, 95% CI 0.7-1.4) or 12 weeks postpartum (51% vs. 56%, OR 0.8, 95% CI 0.6-1.2). They were, however, significantly more likely to be partially breastfeeding on discharge from hospital (10% vs. 2%, OR 5.3, 95% CI 2.3-12.4), at 6 weeks (22% vs. 11%, OR 1.9, 95% CI 1.2-3.2) and 12 weeks postpartum (17% vs. 8%, OR 2.2, 95% CI 1.2-3.9). DISCUSSION: Asian women were more likely than non-Asian women to be giving their baby some breast milk at 6 and 12 weeks postpartum when partial breastfeeding was taken into account. This contradicts popular beliefs amongst midwives regarding the infant feeding practices of Asian women. CONCLUSION: Further research into this important issue is needed in order to improve breastfeeding support for women from different cultural backgrounds. The issue of causes of, and variations in, the levels of partial breastfeeding between different ethnic groups needs more investigation.
Abstract: OBJECTIVE: to explore first-time mothers' experiences of birth at home and in hospital in Australia. DESIGN: a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes. SETTING: Sydney, Australia. PARTICIPANTS: 19 women were interviewed. Seven women who gave in a public hospital and seven women who gave birth for the first time at home were interviewed and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once. FINDINGS: three categories emerged from the analysis: preparing for birth, the novice birthing and processing the birth. These women shared a common core experience of seeing that they gave birth as 'novices'. The basic social process running through their experience of birth, regardless of birth setting, was that, as novices, they were all 'reacting to the unknown'. The mediating factors that influenced the birth experiences of these first-time mothers were preparation, choice and control, information and communication, and support. The quality of midwifery care both facilitated and hindered these needs, contributing to the women's perceptions of being 'honoured'. The women who gave birth at home seemed to have more positive birth experiences. IMPLICATIONS FOR PRACTICE: identifying the novice status of first-time mothers and understanding the way in which they experience birth better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing. It demonstrates how midwives can contribute to positive birth experiences by being aware that first-time mothers, irrespective of birth setting, are essentially reacting to the unknown as they negotiate the experience of birth.
Abstract: Women have traditionally been high users of complementary therapies and use of these therapies continues during pregnancy and birthing. While women look to acupuncture and other therapies to support them during this time, traditional maternity services are in a state of change. In Australia, there is an increase in births, a workforce crisis, an increase in birthing in labour ward settings, few opportunities for women to birth at home, increased caesarean sections and an increase in obstetric interventions. The future role of acupuncture in this changed environment will be influenced by the evidence of safety and effectiveness of acupuncture. Research evaluating acupuncture during the antenatal period, labour preparation and birthing is small in quantity, but there are encouraging findings suggesting acupuncture maybe safe and effective. Women have prioritised interventions to manage pregnancy symptoms such as nausea and back pain, and interventions to prepare for labour and manage pain in labour as important. Further acupuncture trials are needed to ensure women have reliable and valid information to inform their decision making. Assessment of safety requires contributions from researchers, practitioners and integration with institutional data collection systems. Research of effectiveness should involve rigorous designs, but with debate about the appropriateness of traditional randomised controlled trial designs to evaluate complex interventions, and the limitations of sham controls, different approaches with mixed research methods should be considered. Exploring new research methods, especially those which explore the woman's experience with acupuncture, are also key to defining a role in the future.
Abstract: OBJECTIVE: to determine women's and midwives' experiences of using perineal warm packs in the second stage of labour. DESIGN: as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births. SETTING: two hospitals in Sydney, Australia. PARTICIPANTS: a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women. INTERVENTION: warm, moist packs were applied to the perineum in the late second stage of labour. FINDINGS: warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour. KEY CONCLUSIONS: responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort. IMPLICATIONS FOR PRACTICE: perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.
Abstract: OBJECTIVE: to explore the experiences of a small group of first-time mothers giving birth at home or in hospital. DESIGN: a grounded theory methodology was used. Data were generated from in-depth interviews with women in their own homes. SETTING: Sydney, Australia. PARTICIPANTS: 19 women were interviewed. Seven women who gave birth for the first time in a public hospital and seven women who gave birth for the first time at home were interviewed, and their experiences were contrasted with two mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first time in a private hospital and two women who had given birth more than once. RESULTS: these women shared common experiences of giving birth as 'novices'. Regardless of birth setting, they were all 'reacting to the unknown'. As they entered labour, the women chose different levels of responsibility for their birth. They also readjusted their expectations when the reality of labour occurred, reacted to the 'force' of labour, and connected or disconnected from the labour and eventually the baby. IMPLICATIONS FOR PRACTICE: knowing that first-time mothers, irrespective of birth setting, are essentially 'reacting to the unknown' as they negotiate the experience of birth, could alter the way in which care is provided and increase the sensitivity of midwives to women's needs. Most importantly, midwives need to be aware of the need to help women adjust their expectations during labour and birth. Identifying the 'novice' status of first-time mothers also better explains previous research that reports unrealistic expectations and fear that may be associated with first-time birthing.
Abstract: PURPOSE: To determine the views of midwives towards perineal repair and the most effective way to teach and support midwives in developing this skill. PROCEDURE: A questionnaire was distributed to 111 midwives who attended a 1-day seminar. Information was sought on a range of views relating to perineal repair, including experience, confidence, education and accreditation, attitudes and trends. FINDINGS: One hundred and six (96%) questionnaires were returned. All respondents (100%) believed midwives should be taught to undertake perineal repair. The most important reason was to provide continuity of care for women. Experience increased confidence and enjoyment in undertaking perineal repair as well as lessening fears over the impact of suturing on women. Experience did not significantly impact on concerns regarding legal implications associated with perineal repair. Three quarters of respondents reported that midwifery students should have practical experience of perineal repair. There was strong support for doctors and midwives to undertake perineal repair education together (96%), preferably in a 1-day workshop format (56%); for standards to be set by the professional colleges (midwifery and obstetrics) (66%); for midwives and doctors to be accredited as competent before performing perineal repair independently (>90%) and for regular updates in perineal repair (93%). The majority of midwives (73%) felt that they were more likely to suture than 5 years ago, due mainly to a greater appreciation of woman centred care (35%). Over 60% of midwives said they would not suture a first-degree tear more than half of the time and 13% would not suture a second-degree tear more than half of the time. PRINCIPLE CONCLUSION: A desire to provide continuity of care appears to be a major motivator for midwives to learn to undertake perineal repair. There is need for standards to be set for perineal repair to encourage consistency in education. Perineal repair programs that involve midwives and doctors training together have strong support from midwives but it is unclear if doctors would also support this. Further research is needed to support or refute the trend for midwives to not suture some perineal trauma.
Abstract: OBJECTIVES: To describe the postpartum perineal morbidity of primiparous women who had a vaginal birth and compare outcomes between Asian and non-Asian women in the first 2 days following the birth and at 6 and 12 weeks postpartum. DESIGN: Data from a randomized clinical trial of a perineal management technique (perineal warm packs) were used to address the study objective. Setting: Two maternity hospitals in Sydney, Australia. PARTICIPANTS: Primiparous women who had a vaginal birth in the trial were included (n=697). One third of the women were identified as "Asian." RESULTS: Compared with non-Asian women, Asian women were significantly more likely to have an episiotomy; require perineal suturing; sustain a third- or fourth-degree perineal tear; and report their perineal pain as being moderate to severe on day 1 following the birth. Asian women were less likely to give birth in an upright position or to resume sexual intercourse by 6 or 12 weeks following the birth. CONCLUSION: More research is needed into methods that could reduce the high rates of perineal trauma experienced by Asian women, and midwives need to be able to offer appropriate support for Asian women.
Abstract: The aim of this research was to explore the experiences of a group of first-time mothers who had given birth at home or in hospital in Australia. Data were generated from in-depth interviews with 19 women and analyzed using a grounded theory approach. One of the categories to emerge from the analysis, "Preparing for Birth," is discussed in this article. Preparing for Birth consisted of two subcategories, "Finding a Childbirth Setting" and "Setting Up Birth Expectations," which were mediated by beliefs, convenience, finances, reputation, imagination, education and knowledge, birth stories, and previous life experiences. Overall, the women who had planned home births felt more prepared for birth and were better supported by their midwives compared with women who had planned hospital births.
Abstract: BACKGROUND: Perinatal mortality is a rare outcome among babies born at term in developed countries after normal uncomplicated pregnancies; consequently, the numbers involved in large databases of routinely collected statistics provide a meaningful evaluation of these uncommon events. The National Perinatal Data Collection records the place of birth and information on the outcomes of pregnancy and childbirth for all women who give birth each year in Australia. Our objective was to describe the perinatal mortality associated with giving birth in "alongside hospital" birth centers in Australia during 1999 to 2002 using nationally collected data. METHODS: This population-based study included all 1,001,249 women who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. Selected perinatal outcomes (including stillbirths and neonatal deaths) were described for the 4-year study period separately for first-time mothers and for women having a second or subsequent birth. A further comparison was made between deaths of low-risk term babies born in hospitals compared with deaths of term babies born in birth centers. RESULTS: The total perinatal death rate attributed to birth centers was significantly lower than that attributed to hospitals (1.51/1,000 vs 10.03/1,000). The perinatal mortality rate among term births to primiparas in birth centers compared with term births among low-risk primiparas in hospitals was 1.4 versus 1.9 per 1,000; the perinatal mortality rate among term births to multiparas in birth centers compared with term births among low-risk multiparas in hospitals was 0.6 versus 1.6 per 1,000. CONCLUSIONS: This study using Australian national data showed that the overall rate of perinatal mortality was lower in alongside hospital birth centers than in hospitals irrespective of the mother's parity.
Abstract: BACKGROUND: Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. METHODS: A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second-stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention-to-treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. RESULTS: The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third- and fourth-degree tears and they had significantly lower perineal pain scores when giving birth and on "day 1" and "day 2" after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. CONCLUSIONS: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care.
Abstract: OBJECTIVE: to determine risk factors for the occurrence of severe perineal trauma (third and fourth degree tears) during childbirth. DESIGN: a prospective cohort study was conducted using the hospital's computerised obstetric information system. Additional data were gathered on women who sustained severe perineal trauma. Descriptive statistics and logistic regression were used to assess risk factors for severe perineal trauma. Midwives were asked to comment on possible reasons for severe perineal trauma. Written responses made by midwives were analysed using content analysis. Discussion groups with midwives were held to further explore their experiences. SETTING: Royal Prince Alfred Hospital, Sydney, Australia. PARTICIPANTS: all women having vaginal births (n=6595) in a 2-year period between 1 April 1998 and 31 March 2000, in both the birth centre and the labour ward. MEASUREMENTS AND FINDINGS: 2% of women (n=134) experienced severe perineal trauma. One hundred and twenty-two women had third-degree tears and 12 had fourth-degree tears. Primiparity, instrumental delivery, Asian ethnicity and heavier babies were associated with an elevated risk of severe perineal trauma. Midwives identified several factors they believed contributed to severe perineal trauma. These were lack of effective communication with the woman during the birth, different birth positions, delivery technique, ethnicity and obstetric influences. KEY CONCLUSIONS: findings support current knowledge that primiparity, instrumental birth, heavier babies and being of Asian ethnicity are associated with increased rates of severe trauma. Specific attention needs to be paid to the strong association found between being of Asian ethnicity and experiencing severe perineal trauma. IMPLICATIONS FOR PRACTICE: further identification and validation of the concerns expressed by midwives to reduce severe perineal trauma is warranted so that preventative strategies can be used and researched.
Abstract: The paper focuses on possible future pathways in maternity care for midwives and nations to consider. The paper blends personal and professional experiences to outline priority areas facing midwives in the future. It begins by examining maternal mortality and morbidity in the developing world and considering the potential of the ten high priority action messages (1997) in helping to improve the plight of women and children in the future. The paper then examines major issues facing midwives in the developed world including: the way birth is viewed; the medical-midwifery divide; marketing midwifery; and finally the challenge of dealing with fear around birth. The third part of the paper examines a part of society where the two worlds meet and there are issues from both the developed and developing world to consider. The paper focuses on women from culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander women and women birthing in remote and rural areas. By looking at these three worlds separately the paper examines different concerns facing midwives in the future but also draws on common issues that face us all as citizens of this planet and particularly as predominantly women. The paper challenges midwives to be politically active and dare to change the world.
Abstract: OBJECTIVE: To study the association between volume of hospital births per annum and birth outcome for low risk women. DESIGN: Population-based study using the National Perinatal Data Collection (NPDC). SETTING: Australia. PARTICIPANTS: Of 750,491 women who gave birth during 1999-2001, there were 331,147 (47.14%) medically 'low risk' including 132,696 (40.07%) primiparae and 198,451 (59.93%) multiparae. METHODS: The frequency of each birth and infant outcome was described according to the size of the hospital where birth took place. We investigated whether unit size (defined by volume) was an independent risk factor for each outcome factor using public hospitals with greater than 2000 births per annum as a reference point. MAIN OUTCOME MEASURES: Rates of intervention at birth and neonatal mortality for low risk women in relation to hospitals with <100, 100-500, 501-1000, 1001-2000 and >2001 births per annum. RESULTS: Neonatal death was less likely in hospitals with less than 2000 births per annum regardless of parity. For multiparous low risk women in hospitals of 100 and 500 births per annum compared with hospitals of >2000 births per annum the adjusted odds of neonatal mortality [adjusted odds ratio (AOR) 0.36; 99% confidence interval (CI) 0.14-0.93]. For low risk primiparous women in hospitals with less than 100 births per annum, there were lower rates of induction of labour (AOR 0.62; 99% CI 0.54-0.73); intrathecal analgesia/anaesthesia (AOR 0.34; 99% CI 0.28-0.42); instrumental birth (AOR 0.80; 99% CI 0.69-0.93); caesarean section after labour (AOR 0.59; 99% CI 0.49-0.72) and admission to a neonatal unit (AOR 0.15; 99% CI 0.10-0.22) and for low risk multiparous women in hospitals with less than 100 births per annum: induction (AOR 0.69; 99% CI 0.62-0.76); intrathecal analgesia/anaesthesia (AOR 0.32; 99% CI 0.29-0.36); instrumental birth (AOR 0.52; 99% CI 0.41-0.67); caesarean section after labour (AOR 0.41; 99% CI 0.33-0.52); and admission to a neonatal unit (AOR 0.09; 99% CI 0.07-0.12). CONCLUSIONS: In Australia, lower hospital volume is not associated with adverse outcomes for low risk women.
