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Lalor J, Ayers S, Celleja Agius J, Downe S, Gouni O, Hartmann K, Nieuwenhuijze M, Oosterman M, Turner JD, Karlsdottir SI, Horsch A. Balancing restrictions and access to maternity care for women and birthing partners during the COVID-19 pandemic: the psychosocial impact of suboptimal care. BJOG 2021; 128:1720-1725. [PMID: 34268858 PMCID: PMC8441715 DOI: 10.1111/1471-0528.16844] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 11/30/2022]
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Schaaf M, Kapilashrami A, George A, Amin A, Downe S, Boydell V, Samari G, Ruano AL, Nanda P, Khosla R. Unmasking power as foundational to research on sexual and reproductive health and rights. BMJ Glob Health 2021; 6:bmjgh-2021-005482. [PMID: 33832951 PMCID: PMC8039258 DOI: 10.1136/bmjgh-2021-005482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 01/19/2023] Open
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Dahlen HG, Thornton C, Downe S, de Jonge A, Seijmonsbergen-Schermers A, Tracy S, Tracy M, Bisits A, Peters L. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open 2021; 11:e047040. [PMID: 34059509 PMCID: PMC8169493 DOI: 10.1136/bmjopen-2020-047040] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES We compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births. DESIGN We used population linked data from New South Wales, Australia (2001-2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age. RESULTS Of 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years. CONCLUSION IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.
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Feeley C, Crossland N, Betran AP, Weeks A, Downe S, Kingdon C. Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences. Reprod Health 2021; 18:92. [PMID: 33952309 PMCID: PMC8097768 DOI: 10.1186/s12978-021-01146-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/26/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers. METHODS A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence. RESULTS 31 papers, reporting on 27 studies and published 1985-2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised. CONCLUSION Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use.
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Hofmeyr GJ, Bernitz S, Bonet M, Bucagu M, Dao B, Downe S, Galadanci H, Homer C, Hundley V, Lavender T, Levy B, Lissauer D, Lumbiganon P, McConville FE, Pattinson R, Qureshi Z, Souza JP, Stanton ME, Ten Hoope-Bender P, Vannevel V, Vogel JP, Oladapo OT. WHO next-generation partograph: revolutionary steps towards individualised labour care. BJOG 2021; 128:1658-1662. [PMID: 33686760 PMCID: PMC9291293 DOI: 10.1111/1471-0528.16694] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/27/2022]
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Blair M, Downe S, Gordon A, Musgrave L, Homer C, Etherington C. Baby Buddy app evaluation-effective uplift in breast feeding despite unclear mechanism. Mhealth 2021; 7:16. [PMID: 33634199 PMCID: PMC7882275 DOI: 10.21037/mhealth-19-233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/02/2020] [Indexed: 11/06/2022] Open
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Uvnäs-Moberg K, Gross MM, Agius A, Downe S, Calleja-Agius J. Are There Epigenetic Oxytocin-Mediated Effects on the Mother and Infant during Physiological Childbirth? Int J Mol Sci 2020; 21:ijms21249503. [PMID: 33327490 PMCID: PMC7765000 DOI: 10.3390/ijms21249503] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/10/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Studies have shown that long-term positive behavioural and physiological changes are induced in connection with vaginal, physiological birth, and skin-to-skin contact after birth in mothers and babies. Some of these effects are consistent with the effect profile of oxytocin. This scoping review explores whether epigenetic changes of the oxytocin gene and of the oxytocin receptor gene (OTR) are involved in these effects. METHODS We searched Pubmed, Medline, BioMed Central, Cochrane Library, OVID, and Web of Science for evidence of epigenetic changes in connection with childbirth in humans, with a particular focus on the oxytocin system. RESULTS There were no published studies identified that were related to epigenetic changes of oxytocin and its receptor in connection with labour, birth, and skin-to-skin contact after birth in mothers and babies. However, some studies were identified that showed polymorphisms of the oxytocin receptor influenced the progress of labour. We also identified studies in which the level of global methylation was measured in vaginal birth and caesarean section, with conflicting results. Some studies identified differences in the level of methylation of single genes linked to various effects, for example, immune response, metabolism, and inflammation. In some of these cases, the level of methylation was associated with the duration of labour or mode of birth. We also identified some studies that demonstrated long-term effects of mode of birth and of skin-to-skin contact linked to changes in oxytocin function. CONCLUSION There were no studies identified that showed epigenetic changes of the oxytocin system in connection with physiological birth. The lack of evidence, so far, regarding epigenetic changes did not exclude future demonstrations of such effects, as there was a definite role of oxytocin in creating long-term effects during the perinatal period. Such studies may not have been performed. Alternatively, the oxytocin linked effects might be indirectly mediated via other receptors and signalling systems. We conclude that there is a significant lack of research examining long-term changes of oxytocin function and long-term oxytocin mediated adaptive effects induced during physiological birth and skin-to-skin contact after birth in mothers and their infants.
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Bauer GF, Roy M, Bakibinga P, Contu P, Downe S, Eriksson M, Espnes GA, Jensen BB, Juvinya Canal D, Lindström B, Mana A, Mittelmark MB, Morgan AR, Pelikan JM, Saboga-Nunes L, Sagy S, Shorey S, Vaandrager L, Vinje HF. Future directions for the concept of salutogenesis: a position article. Health Promot Int 2020; 35:187-195. [PMID: 31219568 DOI: 10.1093/heapro/daz057] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aaron Antonovsky advanced the concept of salutogenesis almost four decades ago (Antonovsky, Health, Stress and Coping. Jossey-Bass, San Francisco, CA, 1979; Unravelling the Mystery of Health. Jossey-Bass, San Francisco, CA, 1987). Salutogenesis posits that life experiences shape the sense of coherence (SOC) that helps to mobilize resources to cope with stressors and manage tension successfully (determining one's movement on the health Ease/Dis-ease continuum). Antonovsky considered the three-dimensional SOC (i.e. comprehensibility, manageability, meaningfulness) as the key answer to his question about the origin of health. The field of health promotion has adopted the concept of salutogenesis as reflected in the international Handbook of Salutogenesis (Mittelmark et al., The Handbook of Salutogenesis. Springer, New York, 2016). However, health promotion mostly builds on the more vague, general salutogenic orientation that implies the need to foster resources and capacities to promote health and wellbeing. To strengthen the knowledge base of salutogenesis, the Global Working Group on Salutogenesis (GWG-Sal) of the International Union of Health Promotion and Education produced the Handbook of Salutogenesis. During the creation of the handbook and the regular meetings of the GWG-Sal, the working group identified four key conceptual issues to be advanced: (i) the overall salutogenic model of health; (ii) the SOC concept; (iii) the design of salutogenic interventions and change processes in complex systems; (iv) the application of salutogenesis beyond health sector. For each of these areas, we first highlight Antonovsky's original contribution and then present suggestions for future development. These ideas will help guide GWG-Sal's work to strengthen salutogenesis as a theory base for health promotion.
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Kennedy HP, Balaam MC, Dahlen H, Declercq E, de Jonge A, Downe S, Ellwood D, Homer CSE, Sandall J, Vedam S, Wolfe I. The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries. Birth 2020; 47:332-345. [PMID: 33124095 DOI: 10.1111/birt.12504] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.
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Feeley C, Thomson G, Downe S. Understanding how midwives employed by the National Health Service facilitate women's alternative birthing choices: Findings from a feminist pragmatist study. PLoS One 2020; 15:e0242508. [PMID: 33216777 PMCID: PMC7678977 DOI: 10.1371/journal.pone.0242508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/12/2020] [Indexed: 12/30/2022] Open
Abstract
UK legislation and government policy favour women's rights to bodily autonomy and active involvement in childbirth decision-making including the right to decline recommendations of care/treatment. However, evidence suggests that both women and maternity professionals can face challenges enacting decisions outside of sociocultural norms. This study explored how NHS midwives facilitated women's alternative physiological birthing choices-defined in this study as 'birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth'. The study was underpinned by a feminist pragmatist theoretical framework and narrative methodology was used to collect professional stories of practice via self-written narratives and interviews. Through purposive and snowball sampling, a diverse sample in terms of age, years of experience, workplace settings and model of care they operated within, 45 NHS midwives from across the UK were recruited. Data were analysed using narrative thematic that generated four themes that described midwives' processes of facilitating women's alternative physiological births: 1. Relationship building, 2. Processes of support and facilitation, 3. Behind the scenes, 4. Birth facilitation. Collectively, the midwives were involved in a wide range of alternative birth choices across all birth settings. Fundamental to their practice was the development of mutually trusting relationships with the women which were strongly asserted a key component of safe care. The participants highlighted a wide range of personal and advanced clinical skills which was framed within an inherent desire to meet the women's needs. Capturing what has been successfully achieved within institutionalised settings, specifically how, maternity providers may benefit from the findings of this study.
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Dahlen HG, Downe S, Jackson M, Priddis H, de Jonge A, Schmied V. An ethnographic study of the interaction between philosophy of childbirth and place of birth. Women Birth 2020; 34:e557-e566. [PMID: 33176996 DOI: 10.1016/j.wombi.2020.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Organisational culture and place of birth have an impact on the variation in birth outcomes seen in different settings. AIM To explore how childbirth is constructed and influenced by context in three birth settings in Australia. METHOD This ethnographic study included observations of 25 healthy women giving birth in three settings: home (9), two birth centres (10), two obstetric units (9). Individual interviews were undertaken with these women at 6-8 weeks after birth and focus groups were conducted with 37 midwives working in the three settings: homebirth (11), birth centres (10) and obstetric units (16). RESULTS All home birth participants adopted a forward leaning position for birth and no vaginal examinations occurred. In contrast, all women in the obstetric unit gave birth on a bed with at least one vaginal examination. One summary concept emerged, Philosophy of childbirth and place of birth as synergistic mechanisms of effect. This was enacted in practice through 'running the gauntlet', based on the following synthesis: For women and midwives, depending on their childbirth philosophy, place of birth is a stimulus for, or a protection from, running the gauntlet of the technocratic approach to birth. The birth centres provided an intermediate space where the complex interplay of factors influencing acceptance of, or resistance to the gauntlet were most evident. CONCLUSIONS A complex interaction exists between prevailing childbirth philosophies of women and midwives and the birth environment. Behaviours that optimise physiological birth were associated with increasing philosophical, and physical, distance from technocratic childbirth norms.
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McKelvin G, Thomson G, Downe S. The childbirth experience: A systematic review of predictors and outcomes. Women Birth 2020; 34:407-416. [PMID: 33039281 DOI: 10.1016/j.wombi.2020.09.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Birth is often viewed as a pathological event, consequently, there has been an increase in literature focusing on predictors, experience and implications of traumatic childbirth and childbirth-related posttraumatic stress. However, to fully understand childbirth experiences a salutogenic perspective is required. This enables an understanding of what facilitates a positive childbirth experience besides what places women at risk of experiencing traumatic childbirth. OBJECTIVE To identify the psychosocial factors that could contribute to or be influenced by women's subjective accounts of childbirth. METHOD An in-depth literature search across four databases was undertaken. Quality appraisal based on internal and external validity was conducted and a combined numerical summary and categorical description were undertaken. FINDINGS Nineteen papers were included in the review and the variables grouped into three categories. The variables relate to 'Measures of labour and birth experience' (discussing the impact of events and perceptions during labour and birth). The second category discusses how 'support and relationships' can potentially shape the birth experience or be altered by it and finally, 'Psychological variables: influence and impact' is examined extensively. DISCUSSION The results of the review highlight significant contradictory evidence of what influences birth experiences. The findings confirm the dearth of available literature concerning positive birth experiences and most variables identified were pathogenic. This review suggests that such factors for PTSD may differ from those that influence birth experiences and should be examined separately. An enhanced understanding of the range of experiences is required to support women's rights in achieving a positive birth.
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Levett KM, Lord SJ, Dahlen HG, Smith CA, Girosi F, Downe S, Finlayson KW, Fleet J, Steen M, Davey MA, Newnham E, Werner A, Arnott L, Sutcliffe K, Seidler AL, Hunter KE, Askie L. The AEDUCATE Collaboration. Comprehensive antenatal education birth preparation programmes to reduce the rates of caesarean section in nulliparous women. Protocol for an individual participant data prospective meta-analysis. BMJ Open 2020; 10:e037175. [PMID: 32967876 PMCID: PMC7513601 DOI: 10.1136/bmjopen-2020-037175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/09/2020] [Accepted: 08/14/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Rates of medical interventions in normal labour and birth are increasing. This prospective meta-analysis (PMA) proposes to assess whether the addition of a comprehensive multicomponent birth preparation programme reduces caesarean section (CS) in nulliparous women compared with standard hospital care. Additionally, do participant characteristics, intervention components or hospital characteristics modify the effectiveness of the programme? METHODS AND ANALYSIS: Population: women with singleton vertex pregnancies, no planned caesarean section (CS) or epidural.Intervention: in addition to hospital-based standard care, a comprehensive antenatal education programme that includes multiple components for birth preparation, addressing the three objectives: preparing women and their birth partner/support person for childbirth through education on physiological/hormonal birth (knowledge and understanding); building women's confidence through psychological preparation (positive mindset) and support their ability to birth without pain relief using evidence-based tools (tools and techniques). The intervention could occur in a hospital-based or community setting.Comparator: standard care alone in hospital-based maternity units. OUTCOMES Primary: CS.Secondary: epidural analgesia, mode of birth, perineal trauma, postpartum haemorrhage, newborn resuscitation, psychosocial well-being.Subgroup analysis: parity, model of care, maternal risk status, maternal education, maternal socio-economic status, intervention components. STUDY DESIGN An individual participant data (IPD) prospective meta-analysis (PMA) of randomised controlled trials, including cluster design. Each trial is conducted independently but share core protocol elements to contribute data to the PMA. Participating trials are deemed eligible for the PMA if their results are not yet known outside their Data Monitoring Committees. ETHICS AND DISSEMINATION Participants in the individual trials will consent to participation, with respective trials receiving ethical approval by their local Human Research Ethics Committees. Individual datasets remain the property of trialists, and can be published prior to the publication of final PMA results. The overall data for meta-analysis will be held, analysed and published by the collaborative group, led by the Cochrane PMA group. TRIAL REGISTRATION NUMBER CRD42020103857.
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Renfrew MJ, Cheyne H, Craig J, Duff E, Dykes F, Hunter B, Lavender T, Page L, Ross-Davie M, Spiby H, Downe S. Sustaining quality midwifery care in a pandemic and beyond. Midwifery 2020; 88:102759. [PMID: 32485502 PMCID: PMC7247475 DOI: 10.1016/j.midw.2020.102759] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022]
Abstract
•Rapid development of COVID-19 has altered healthcare and services around the world; changes have affected women, newborn infants, families, and staff •Restrictive practices have been introduced in maternal and newborn care that limit women's decisions and rights of women and newborn infants, including restrictions on the place of birth, continuity of care, and mother-baby contact •An evidence-informed approach is now developing in some countries in which essential elements of quality can be maintained while also protecting and supporting staff •To keep women, newborn infants, families, and staff safe, balance is needed between the public health, quality care, and human rights agendas •A set of key principles is proposed to inform COVID-relevant quality care and service provision •A pro-active strategy to inform longer-term planning for life during and after the pandemic should be grounded in evidence and co-created with women, families, and staff
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Downe S, Calleja Agius J, Balaam MC, Frith L. Understanding childbirth as a complex salutogenic phenomenon: The EU COST BIRTH Action Special Collection. PLoS One 2020; 15:e0236722. [PMID: 32756586 PMCID: PMC7406045 DOI: 10.1371/journal.pone.0236722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In 2014, the EU funded a four-year European Cooperation in Science and Technology (COST) Action to address the topic of childbirth. The COST Birth Action was a cross-European network, that brought together over 120 scientists, practitioners, activists and policy makers from 34 countries to work on intrapartum care. The central aim was to advance the state of research and practice in a specific area of great clinical and social importance, intrapartum care. The Action used inter and trans-disciplinary approaches to address birth from multiple perspectives and drew on complexity theory and the concept of salutogenesis (wellbeing). This special collection presents six papers produced from the Action and gives a sense of the range and depth of the work conducted. The Collection illustrates the knowledge that can be generated when a diverse group of people come together with a similar goals and perspectives.
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Hundley V, Downe S, Buckley SJ. The initiation of labour at term gestation: Physiology and practice implications. Best Pract Res Clin Obstet Gynaecol 2020; 67:4-18. [DOI: 10.1016/j.bpobgyn.2020.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 11/16/2022]
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Kasiteropoulou D, Topalidou A, Downe S. A computational fluid dynamics modelling of maternal-fetal heat exchange and blood flow in the umbilical cord. PLoS One 2020; 15:e0231997. [PMID: 32722669 PMCID: PMC7386597 DOI: 10.1371/journal.pone.0231997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022] Open
Abstract
Human fetal thermoregulation, maternal-fetal heat exchange, and the role of the umbilical cord in these processes are not well understood. Ethical and technical limitations have restricted current knowledge to animal studies, that do not reflect human morphology. Here, we present the first 3-dimensional computational model of the human umbilical cord with finite element analysis, aiming to compute the maternal-fetal heat exchange. By modelling both the umbilical vein and the two umbilical arteries, we found that the coiled geometry of the umbilical artery, in comparison with the primarily straight umbilical vein, affects blood flow parameters such as velocity, pressure, temperature, shear strain rate and static entropy. Specifically, by enhancing the heat transfer coefficient, we have shown that the helical structure of the umbilical arteries plays a vital role in the temperature drop of the blood, along the arterial length from the fetal end to the placental end. This suggests the importance of the umbilical cord structure in maternal-fetal heat exchange and fetal heat loss, opening the way for future research with modified models and scenarios, as the basis for early detection of potential heat-transfer related complications, and/or assurance of fetal wellbeing.
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Horsch A, Lalor J, Downe S. Moral and mental health challenges faced by maternity staff during the COVID-19 pandemic. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2020; 12:S141-S142. [PMID: 32478557 DOI: 10.1037/tra0000629] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The current COVID-19 pandemic places maternity staff at risk of engaging in clinical practice that may be in direct contravention with evidence; professional recommendations; or, more profoundly, deeply held ethical or moral beliefs and values, as services attempt to control the risk of cross-infection. Practice changes in some settings include reduction in personal contacts for tests, treatments and antenatal and postnatal care, exclusion of birth partners for labor and birth, separation of mother and baby in the immediate postnatal period, restrictions on breastfeeding, and reduced capacity for hands-on professional labor support through social distancing and use of personal protective equipment. These enforced changes may result in increasing levels of occupational moral injury that need to be addressed at both an organizational and a personal level. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Crossland N, Kingdon C, Balaam MC, Betrán AP, Downe S. Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review. Reprod Health 2020; 17:83. [PMID: 32487226 PMCID: PMC7268509 DOI: 10.1186/s12978-020-00915-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use. METHODS Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix. RESULTS Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies. CONCLUSIONS Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.
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Finlayson K, Crossland N, Bonet M, Downe S. What matters to women in the postnatal period: A meta-synthesis of qualitative studies. PLoS One 2020; 15:e0231415. [PMID: 32320424 PMCID: PMC7176084 DOI: 10.1371/journal.pone.0231415] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The postnatal period is an underserved aspect of maternity care. Guidelines for postnatal care are not usually informed by what matters to the women who use it. This qualitative systematic review was undertaken to identify what matters to women in the postnatal period, to inform the scope of a new World Health Organization (WHO) postnatal guideline. METHODS We searched MEDLINE, CINAHL, PsycINFO, POPLINE, Global Index Medicus, EMBASE, LILACS, AJOL, and reference lists of eligible studies published January 2000-July 2019, reporting qualitative data on women's beliefs, expectations, and values relating to the postnatal period. DATA COLLECTION AND ANALYSIS Author findings were extracted, coded and synthesised using techniques derived from thematic synthesis. Confidence in the quality, coherence, relevance and adequacy of data underpinning the resulting findings was assessed using GRADE-CERQual. RESULTS We included 36 studies from 15 countries, representing the views of more than 800 women. Confidence in most results was moderate to high. What mattered to women was a positive postnatal experience where they were able to adapt to their new self-identity and develop a sense of confidence and competence as a mother; adjust to changes in their intimate and family relationships, including their relationship to their baby; navigate ordinary physical and emotional challenges; and experience the dynamic achievement of personal growth as they adjust to the 'new normal' of motherhood and parenting in their own cultural context. CONCLUSION This review provides evidence that what matters to women in the postnatal period is achieving positive motherhood (including maternal self-esteem, competence, and autonomy), as well as fulfilling adaptation to changed intimate and family relationships, and (re)gaining health and wellbeing for both their baby, and themselves. Where this process is optimal, it also results in joy, self-confidence, and an enhanced capacity to thrive in the new integrated identity of 'woman and mother'.
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McKeown M, Thomson G, Scholes A, Jones F, Downe S, Price O, Baker J, Greenwood P, Whittington R, Duxbury J. Restraint minimisation in mental health care: legitimate or illegitimate force? An ethnographic study. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:449-464. [PMID: 31657030 DOI: 10.1111/1467-9566.13015] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.1 A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the 'REsTRAIN Yourself' (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma-informed care represents a potentially alternative legitimacy.
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Stoll KH, Downe S, Edmonds J, Gross MM, Malott A, McAra-Couper J, Sadler M, Thomson G. A Survey of University Students' Preferences for Midwifery Care and Community Birth Options in 8 High-Income Countries. J Midwifery Womens Health 2020; 65:131-141. [PMID: 31957228 DOI: 10.1111/jmwh.13069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Midwifery care is associated with positive birth outcomes, access to community birth options, and judicious use of interventions. The aim of this study was to characterize and compare maternity care preferences of university students across a range of maternity care systems and to explore whether preferences align with evidence-based recommendations and options available. METHODS A cross-sectional, web-based survey was completed in 2014 and 2015 by a convenience sample of university students in 8 high-income countries across 4 continents (N = 4569). In addition to describing preferences for midwifery care and community birth options across countries, this study examined sociodemographic characteristics, psychological factors, knowledge about pregnancy and birth, and sources of information that shaped students' attitudes toward birth in relation to preferences for midwifery care and community birth options. RESULTS Approximately half of the student respondents (48.2%) preferred midwifery-led care for a healthy pregnancy; 9.5% would choose to give birth in a birthing center, and 4.5% preferred a home birth. Preference for midwifery care varied from 10.3% among women in the United States to 78.6% among women in the United Kingdom. Preferences for home birth varied from 0.3% among US women to 18.3% among Canadian women. Women, health science students, those with low childbirth fear, those who learned about pregnancy and birth from friends (compared with other sources, eg, the media), and those who responded from Europe were significantly more likely to prefer midwifery care and community birth. High confidence in knowledge of pregnancy and birth was linked to significantly higher odds of community birth preferences and midwifery care preferences. DISCUSSION It would be beneficial to integrate childbirth education into high school curricula to promote knowledge of midwifery care, pregnancy, and childbirth and to reduce fear among prospective parents. Community birth options need to be expanded to meet demand among the next generation of maternity service users.
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Ebrahimoff M, Many A, Downe S, Tishkovskaya S, Hall-Moran V. Length of labour in mothers and their daughters: A matched cohort study. Eur J Obstet Gynecol Reprod Biol 2019; 245:77-83. [PMID: 31884149 DOI: 10.1016/j.ejogrb.2019.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 12/12/2019] [Accepted: 12/22/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Physiological length of labour is highly variable and population norms have low sensitivity and specificity for individuals. The birth history of mothers may provide a basis for personalized assessment of labour progress in their nulliparous daughters. This study was designed to investigate the relationship between length of labour in nulliparous daughters and in their mother's first birth, as a basis for constructing individualised labour prediction models in future. STUDY DESIGN A mother-daughter matched cohort study was conducted in two Israeli maternity hospitals. Recruitment took place between September 2014 and June 2015 via antenatal clinics. Inclusion criteria were nulliparous daughters with singleton pregnancies at ≥32 weeks' gestation and mothers of included daughters who had a first birth in hospital prior to 1997. Data were collected prospectively for daughters by questionnaire and from electronic hospital records, and through retrospective recall questionnaires for mothers. Mother-daughter length of labour data were analysed using parametric and non-parametric tests and logistic regression. Length of labour was categorized as ≤10 h and >10 h. Other factors influencing daughters' length of labour were also examined. RESULTS Data from 323 mother-daughter pairs were analysed. Univariate logistic regression analysis showed that daughters of mothers who were in active labour for more than 10 h showed increased likelihood of having a longer labour [OR1.91 (95 % CI 1.19, 3.05, P = 0.007)]. Controlling for infant gender increased the effect size [OR3.23 (95 % CI 1.55, 6.74, P = 0.002)]. Multivariable logistic regression indicated that mothers' length of labour [OR1.88 (95 % CI 1.12, 3.17)] and daughters' age [OR1.08 (95 % CI 1.02, 1.14)], weight gain in pregnancy [OR1.10 (95 % CI 1.04, 1.16)] and use of anesthesia, were statistically significant factors for daughters' length of labour, with sensitivity, specificity, and positive and negative predictive values of 74 %, 56 %, 66 %, and 64 %, respectively. CONCLUSIONS A strong positive association between mother and daughter lengths of labour was found. A model that includes length of labour in their mother's first birth might be useful for labour progress prediction for nulliparous women. Practitioners could inquire about maternal first birth patterns as an additional heuristic to guide practice and increase precision in the clinical management of nullipara women's labour and delivery.
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Althabe F, Therrien MNS, Pingray V, Hermida J, Gülmezoglu AM, Armbruster D, Singh N, Guha M, Garg LF, Souza JP, Smith JM, Winikoff B, Thapa K, Hébert E, Liljestrand J, Downe S, Garcia Elorrio E, Arulkumaran S, Byaruhanga EK, Lissauer DM, Oguttu M, Dumont A, Escobar MF, Fuchtner C, Lumbiganon P, Burke TF, Miller S. Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation. Int J Gynaecol Obstet 2019; 148:290-299. [PMID: 31709527 PMCID: PMC7064978 DOI: 10.1002/ijgo.13028] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 09/16/2019] [Accepted: 11/08/2019] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To systematically develop evidence-based bundles for care of postpartum hemorrhage (PPH). METHODS An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated "GRADE Evidence-to-Decision" framework. Twenty-three global maternal-health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6-month period, the expert panel met online and via teleconferences, culminating in a 2-day in-person meeting. RESULTS The consultation led to the definition of two care bundles for facility implementation. The "first response to PPH bundle" comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The "response to refractory PPH bundle" comprises compressive measures (aortic or bimanual uterine compression), the non-pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements. CONCLUSION For the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.
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Opiyo N, Kingdon C, Oladapo OT, Souza JP, Vogel JP, Bonet M, Bucagu M, Portela A, McConville F, Downe S, Gülmezoglu AM, Betrán AP. Non-clinical interventions to reduce unnecessary caesarean sections: WHO recommendations. Bull World Health Organ 2019; 98:66-68. [PMID: 31902964 PMCID: PMC6933434 DOI: 10.2471/blt.19.236729] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022] Open
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