Continuous support for women during childbirth

Assessing the Gap Between Women's Expectations and Perceptions of the Quality of Intrapartum Care in Jordan: A Two-Stage Study Using the SERVQUAL Model

INTRODUCTION

Although Jordan has made significant progress toward expanding the utilization of facility-based intrapartum care, prior research highlights that poor service quality is still persistent. This study aimed to identify quality gaps between women's expectations and perceptions of the actual intrapartum care received, while exploring the contributing factors.

METHODS

Utilizing a pre-post design, quality gaps in intrapartum care were assessed among 959 women pre- and postchildbirth at a prominent tertiary hospital in northern Jordan. Data were gathered using the SERVQUAL scale, measuring service quality across reliability, responsiveness, tangibles, assurance, and empathy dimensions.

RESULTS

The overall mean gap score between women's expectations and perceptions of the quality of intrapartum care was -0.60 (±0.56). The lowest and highest mean gap scores were found to be related to tangibles and assurance dimensions, -0.24 (±0.39) and -0.88 (±0.35), respectively. Significant negative quality gaps were identified in the dimensions of assurance, empathy, and responsiveness, as well as overall service quality (p < 0.001). The MLR analyses highlighted education (β = 0.61), mode of birth (β = -0.60), admission timing (β = -0.41), continuity of midwifery care (β = -0.43), physician's gender (β = -0.62), active labour duration (β = 0.37), and pain management (β = -0.33) to be the key determinants of the overall quality gap in intrapartum care.

CONCLUSION

Our findings underscore the importance of fostering a labour environment that prioritizes enhancing caregivers' empathetic, reassuring, and responsive skills to minimize service quality gaps and enhance the overall childbirth experience for women in Jordan.

PATIENT OR PUBLIC CONTRIBUTION

This paper is a collaborative effort involving women with lived experiences of childbirth, midwives, and obstetrics and gynaecologist physicians. The original idea, conceptualization, data generation, and coproduction, including manuscript editing, were shaped by the valuable contributions of stakeholders with unique perspectives on intrapartum care in Jordan.

'Do we need doulas…?' - Perspectives of maternity care managers on the role of doulas in Poland

AIM

The purpose of this study was to analyse perinatal care managers' perspectives on the role of doulas in Poland and to consider how managers' perspectives might affect the opportunities for doulas to practice in individual hospitals.

DESIGN

This is a qualitative descriptive study.

METHOD

The total of 17 hospitals was selected for the study. Semi-structured interviews were conducted with 11 manager staff members.

RESULTS

Three groups of facilities were identified: '0' (n = 6) - refused to give interviews, 'A' (n = 8) - marginal experience in working with doulas, and 'B' (n = 3) - regular experience in working with doulas. The hospitals from Group A showed indifference towards working with doulas. Group B declared a positive attitude towards such cooperation. Attitudes towards doulas vary among executives and are related to the frequency of doula-assisted births. Our results indicate factors that may influence the attitude of medical staff towards doulas and which may contribute to improve future initiatives meant to facilitate collaboration between midwives and doulas.

PATIENT OR PUBLIC CONTRIBUTION

This study explored the lived experiences of perinatal care managers.

[Violated birth integrity during the COVID-19 pandemic in Germany: experiences of women with maternity care]

INTRODUCTION

The COVID-19 pandemic may increase women's vulnerability through violations of their integrity during birth. In a cross-sectional study (March 2020 to March 2022), we investigated how women giving birth experienced maternity care during the pandemic in Germany and which factors were associated with their birth integrity.

METHODS

In a survey (validated questionnaire and two open-ended questions), women ≥ 18 years described their experiences of maternity care. We conducted quantitative analyses using descriptive statistics and logistic regressions to investigate factors associated with dignified care and emotional support, which are understood as proxies of birth integrity. We analysed the open-ended questions through inductive content analysis.

RESULTS

We included data from 1271 participants and 214 comments. The majority of respondents felt emotionally supported (71%) and treated with dignity (76%). One third reported not always being involved in decision-making, while 14% felt they were subjected to physical, verbal or emotional abuse. For 57% of women, their companion of choice was absent or their presence limited. Those factors were all associated with the chances of feeling treated with dignity and emotionally supported. The qualitative comments provided an insight into what specifically women perceive as violating their integrity.

DISCUSSION

During the COVID-19 pandemic, the vulnerability of parturients lies in the violation of their birth integrity. Measures to promote respectful maternity care of women who give birth include comprehensive structural and political solutions as well as further research on the determinants of birth integrity.

Laboring Alone: Perinatal Outcomes during Childbirth without a Birth Partner or Other Companion during the COVID-19 Pandemic

During the first wave of the COVID-19 pandemic in the spring of 2020, the government of the Czech Republic issued a nationwide ban on visitors to maternity wards. We studied whether the absence of a close person during labor due to this ban impacted perinatal indicators. This study was performed using an administrative observational questionnaire focused on absolute frequencies of events sent to maternity facilities across the Czech Republic. Completed answers were received from 33 facilities covering 4805 births during the study period in 2019 and 4514 births in 2020. The differences in individual parameters were tested using Pearson's chi-squared homogeneity test. There were no significant differences between the two periods in spontaneous pre-term births (p = 0.522) or in the number of cesarean sections (p = 0.536). No significant changes were seen in either local or systemic analgesia. Data showed a significantly shorter (p = 0.026) first stage of labor in 2020 compared to 2019, while there was no significant difference (p = 0.673) in the second stage of labor. There was no statistically significant difference found for newborn perinatal adaptation. There were also no significant differences in intrapartum maternal injuries. Overall, we found no significant differences in basic perinatal indicators during the first wave of COVID-19 in 2020 compared to 2019. Although the absence of a close person may cause stress for the laboring women, it does not impair objective clinical outcomes.

Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth

Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.

Trend and Sociodemographic Correlates of Cesarean Section Utilization in Nepal: Evidence from Demographic and Health Surveys 2006-2016

BACKGROUND

Addressing inequalities in accessing emergency obstetric care is crucial for reducing the maternal mortality ratio. This study was undertaken to examine the time trends and sociodemographic correlates of cesarean section (CS) utilization in Nepal between 2006 and 2016. Methods. Data from the Nepal Demographic and Health Surveys (NDHS) 2006, 2011, and 2016 were sourced for this study. Women who had a live birth in the last five years of the survey were the unit of analysis for this study. Absolute and relative inequalities in CS utilization were expressed in terms of rate difference and rate ratios, respectively. We used multivariable regression models to assess the CS rate by background sociodemographic characteristics of women.

RESULTS

Age and parity-adjusted CS rates were found to have increased almost threefold (from 3.2%, 95% CI: 2.1-4.3 in 2006 to 10.5%; 95% CI: 8.9-11.9 in 2016) over the decade. In 2016, women from mountain region (3.0%), those from the lowest wealth quintile (2.4%), and those living in Karnali province (2.4%) had CS rate below 5%. Whereas women from the highest wealth quintile (25.1%), with higher education (21.2%), and those delivering in private facilities (37.1%) had CS rate above 15%. Women from the highest wealth quintile (OR-3.3; 95% CI: 1.6-7.0) compared to women from the lowest wealth quintile and those delivered in private/NGO-run facilities (OR-3.6; 95% CI: 2.7-4.9) compared to women delivering in public facilities were more than three times more likely to deliver by CS.

CONCLUSION

To improve maternal and newborn health, strategies need to be revised to address the underuse of CS among poor, those living in mountain region and Province 2, Lumbini province, Karnali province, and Sudhurpaschim province. Simultaneously, there is a pressing need for policies, guidelines, and continuous monitoring of CS rates to reduce overuse among rich women, women with higher education, and those giving childbirth in private facilities.

Comparison of Spinal Versus Epidural Analgesia for Vaginal Delivery: A Randomized Double Blinded Clinical Trial

Background

Recently, one of the problems in developing countries is pregnant women who insist on cesarean section for fear of painful vaginal delivery. There are various methods to reduce labor pain, including medical and non-medical methods. Neuraxial analgesia is classified as one of the best ways to reduce labor pain. Epidural analgesia is a classic and popular procedure to decrease labor pain. Nevertheless, other methods, such as spinal or combined spinal-epidural analgesia, is more effective compared with the epidural.

Objectives

In this study, we investigated a single intrathecal versus epidural injection in pregnant women during childbirth.

Methods

In our research, after obtaining informed consent, the patients were randomly assigned to two equal groups: epidural and spinal. Each group contained 50 parturient women in advanced labor. In the epidural group, 2.5 mL isobaric bupivacaine 0.5%, sufentanil (0.2 mcg/mL), and 7 mL saline 0.9% were injected by an 18-gauge Tuohy needle at the L4-5 or L5-S1 intervertebral space, and in the spinal group, 0.5 mL isobaric bupivacaine 0.5%, 2.5 mcg sufentanil, and 0.5 mL saline 0.9% were injected by a 25-gauge pencil-point Quincke needle at the L4-5 or L5-S1 intervertebral spaces. For pain intensity, the visual analog scale (VAS) was used at serial intervals, and other variables, such as the onset and duration of analgesia, hypotension, neonatal APGAR score, fetal heart rate (FHR) changes, and other variables were examined.

Results

The mean time to onset analgesic effect was 4.6 min in the spinal group compared with 12.5 minutes in the epidural (P < 0.001). Duration of analgesia was 121 minutes in the spinal group compared with 104 min in the epidural group (P < 0.001). The time to reach the maximum block was 8.4 min in the spinal group vs. 22.2 min in the epidural group (P < 0.001). The duration of the second and third gestation stages was the same in both groups.

Conclusions

Spinal analgesia is short and easy to perform and does not require advanced equipment and technical experience. Spinal analgesia can be a good option for labor analgesia and leads to achieving a lower pain score than epidural analgesia.

Improving the Caesarean Decision by Robson Classification: A Population-Based Study by 5,323,500 Livebirth Data

Background

Caesarean section is a major obstetric intervention for saving lives of women and their newborns from pregnancy- and childbirth-related complications. C-Section rate is considered an important indicator for measuring obstetric services in any country, region, or institution. In many countries, based on population, all-cause C-Section rates have increased steadily during the past half century. The high and rising C-Section rate is certainly a cause for concern, and evidence-based information is needed as to how or why the C-Section rate has increased and what needs to be done. In this study, we tried to demonstrate how the Robson Classification can be used as a common starting point to audit caesarean deliveries.

Objectives

Given the lack of a scientifically proven classification system to observe and compare caesarean rates, the WHO proposes adopting the Robson's criteria-related grouping as an internationally applicable C-Section classification system.

Methods

We conducted a retrospective study to look into the relation of Robson Criteria and C-Section. Our four years of study encompass 5,323,500 livebirths in Turkey and provide an important source of information for evaluating statistical data.

Findings

We analysed pregnancies according to the percentage of live births in Robson's groups and the caesarean rate within the Robson's groups. In total, 2,764,373 pregnant women have undergone caesarean over 4 years with a 51.9% C-Section rate. According to our findings, as time progresses, the R5 group are expanding due to the caesarean sections groups R1-R4.The R5 group C-Section rate increased regularly from 22.2% in 2013 to 24.3% in 2016. Caesarean sections performed in R1-R4 groups cause subsequent pregnancies of these women to result in caesarean section.

Conclusions

Our results suggest the Robson classification system will help in analysing, screening, auditing, and comparing caesarean rates across different hospitals, countries, or regions and will help to create and implement effective strategies specifically to reach WHO recommended C-Section rates.

Childbirth Experience Questionnaire (CEQ): research proposal for translation and validation into Sinhala language among a Lankan cohort of women

INTRODUCTION

The Childbirth Experience Questionnaire (CEQ) is a Sweden origin, self-administered questionnaire to assess birth satisfaction of women in different aspects of their first labour and birth. It measures four main domains of the woman's childbirth experience. Those are own capacity, professional support, perceived safety and participation, comprising of 22 items.

OBJECTIVES

To conduct a linguistic translation, to conduct a validation study and to assess the psychometric properties of the Sinhala version of the CEQ.

Skilled health attendants' knowledge and practice of pain management during labour in health care facilities in Ibadan, Nigeria

INTRODUCTION

Skilled health attendants occupy an important position in the management of women's pain during labour. Their professional goal is to ensure safety and minimum pain in labour. It has been revealed that nurse-midwives are deficient in knowledge and practice of pain management during labour. Hence, this study examined skilled health attendants' knowledge and practice of pain management in health care facilities in Ibadan, Nigeria.

METHODS

A cross-sectional design was used to collect data from 227 skilled health attendants, in the maternity units of the three purposively selected hospitals for 12 weeks. A structured questionnaire and observational check lists were used for data collection. Data were analyzed using descriptive statistics and significants level was set with p<0.05.

RESULTS

Results on respondents' level of knowledge revealed that 6% had low knowledge, 40.5% moderate, and 56.8% had a high level. The majority, 79.7%, were registered nurse-midwives (RN/RM) and 90.1% employed reassurance for pain relief. No significant associations were found between respondents' level of education and reassurance, exercise, allay of fear, use of drugs, and TENS (p>0.05). However, there were significant associations between respondents' educational level and rubbing of back/massage, position change, cold/warm bath, relaxation, and social support (p<0.05).

CONCLUSIONS

It is recommended that seminars and workshops should be organized regularly and assessment tools should be supplied, to enhance effective pain assessment as this will provide adequate and holistic labour-pain management by nurse-midwives.

Parenteral opioids for maternal pain management in labour

BACKGROUND

Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.

OBJECTIVES

To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.

MAIN RESULTS

We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.

AUTHORS' CONCLUSIONS

Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

Anesthesiologists' Preferences regarding Visitor Presence during Placement of Neuraxial Labor Analgesia

INTRODUCTION

Neuraxial labor analgesia has become an integral part of modern obstetric anesthetic practice. Presence of a familiar person during its placement may be beneficial to the patient. A survey was sent to anesthesiologists practicing obstetric anesthesia in the USA to determine their views.

METHODS

The survey queried the following: existence of a written policy; would they allow a visitor; visitor's view, sitting or standing; reasons to allow or not allow a visitor; and influence by other staff on the decision. The responses were analyzed using multiple chi-square analyses.

RESULTS

Most practitioners supported allowing a visitor during placement. Reduction of patient anxiety and fulfillment of patient request were the major reasons for allowing a visitor. Sitting position and no view of the workspace were preferred. Visitor interference and safety were cited as the major reasons for precluding a visitor. Nonanesthesia providers rarely influenced the decision. Epidural analgesia was the preferred technique. Essentially no bias was found in the responses; there was statistical uniformity regardless of procedures done per week, years in practice, professional certification, geographic region (rural, urban, or suburban), or academic, private, or government responders.

CONCLUSION

The practice of visitor presence during the placement of neuraxial labor analgesia is gaining acceptance.

When the baby remains there for a long time, it is going to die so you have to hit her small for the baby to come out": justification of disrespectful and abusive care during childbirth among midwifery students in Ghana

Despite global attention, high levels of maternal mortality continue to plague many low- and middle-income settings. One important way to improve the care of women in labour is to increase the proportion of women who deliver in a health facility. However, due to poor quality of care, including being disrespected and abused, women are reluctant to come to facilities for delivery care. The current study sought to examine disrespectful and abusive treatment towards labouring women from the perspective of midwifery students who were within months of graduation. Key Messages •Midwifery students in Ghana’s public midwifery schools report witnessing and participating in many forms of disrespect and abuse during deliveries as part of their education. While they are clear as to why respectful care is important and necessary, they are able to justify and explain reasons for disrespectful and abusive care. This poor treatment of labouring women was explicitly and tacitly supported by these students’ teachers and preceptors. •All study materials and methods were reviewed and approved by the Ghana Health Service Ethical Review Committee, the Kwame Nkrumah University of Science and Technology Committee on Publication and Human Ethics, and the University of Michigan Institutional Review Board. •This research was made possible through a grant from the African Studies Center, University of Michigan. For this study, we conducted focus groups with final year midwifery students at 15 public midwifery training colleges in all 10 of Ghana’s regions. Focus group discussions were recorded and transcribed. A multi-disciplinary team of researchers from the US and Ghana analysed the qualitative data. While students were able to talk at length as to why respectful care is important, they were also able to recount times when they both witnessed and participated in disrespectful and abusive treatment of labouring women. The themes which emerged from these data are: 1) rationalization of disrespectful and abusive care; 2) the culture of blame and; 3) no alternative to disrespect and abuse. Although midwifery students in Ghana’s public midwifery schools highlight the importance of providing high-quality, patient-centred respectful care, they also report many forms of disrespect and abuse during childbirth. Without better quality care, including making care more humane, the use of facility-based maternity services in Ghana is likely not to improve. This study provides an important starting point for educators, researchers, and policy makers to re-think how the next generation of healthcare providers needs to be prepared to provide high-quality, respectful care to women during labour and delivery in low-resource settings.

Continuous support for women during childbirth

BACKGROUND

Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine.

OBJECTIVES

The primary objective was to assess the effects, on women and their babies, of continuous, one-to-one intrapartum support compared with usual care, in any setting. Secondary objectives were to determine whether the effects of continuous support are influenced by:1. Routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour, including: policies about the presence of support people of the woman's own choosing; epidural analgesia; and continuous electronic fetal monitoring.2. The provider's relationship to the woman and to the facility: staff member of the facility (and thus has additional loyalties or responsibilities); not a staff member and not part of the woman's social network (present solely for the purpose of providing continuous support, e.g. a doula); or a person chosen by the woman from family members and friends;3. Timing of onset (early or later in labour);4. Model of support (support provided only around the time of childbirth or extended to include support during the antenatal and postpartum periods);5. Country income level (high-income compared to low- and middle-income).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 June 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care. Quasi-randomised and cross-over designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We sought additional information from the trial authors. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included a total of 27 trials, and 26 trials involving 15,858 women provided usable outcome data for analysis. These trials were conducted in 17 different countries: 13 trials were conducted in high-income settings; 13 trials in middle-income settings; and no studies in low-income settings. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (average RR 1.08, 95% confidence interval (CI) 1.04 to 1.12; 21 trials, 14,369 women; low-quality evidence) and less likely to report negative ratings of or feelings about their childbirth experience (average RR 0.69, 95% CI 0.59 to 0.79; 11 trials, 11,133 women; low-quality evidence) and to use any intrapartum analgesia (average RR 0.90, 95% CI 0.84 to 0.96; 15 trials, 12,433 women). In addition, their labours were shorter (MD -0.69 hours, 95% CI -1.04 to -0.34; 13 trials, 5429 women; low-quality evidence), they were less likely to have a caesarean birth (average RR 0.75, 95% CI 0.64 to 0.88; 24 trials, 15,347 women; low-quality evidence) or instrumental vaginal birth (RR 0.90, 95% CI 0.85 to 0.96; 19 trials, 14,118 women), regional analgesia (average RR 0.93, 95% CI 0.88 to 0.99; 9 trials, 11,444 women), or a baby with a low five-minute Apgar score (RR 0.62, 95% CI 0.46 to 0.85; 14 trials, 12,615 women). Data from two trials for postpartum depression were not combined due to differences in women, hospitals and care providers included; both trials found fewer women developed depressive symptomatology if they had been supported in birth, although this may have been a chance result in one of the studies (low-quality evidence). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, such as admission to special care nursery (average RR 0.97, 95% CI 0.76 to 1.25; 7 trials, 8897 women; low-quality evidence), and exclusive or any breastfeeding at any time point (average RR 1.05, 95% CI 0.96 to 1.16; 4 trials, 5584 women; low-quality evidence).Subgroup analyses suggested that continuous support was most effective at reducing caesarean birth, when the provider was present in a doula role, and in settings in which epidural analgesia was not routinely available. Continuous labour support in settings where women were not permitted to have companions of their choosing with them in labour, was associated with greater likelihood of spontaneous vaginal birth and lower likelihood of a caesarean birth. Subgroup analysis of trials conducted in high-income compared with trials in middle-income countries suggests that continuous labour support offers similar benefits to women and babies for most outcomes, with the exception of caesarean birth, where studies from middle-income countries showed a larger reduction in caesarean birth. No conclusions could be drawn about low-income settings, electronic fetal monitoring, the timing of onset of continuous support or model of support.Risk of bias varied in included studies: no study clearly blinded women and personnel; only one study sufficiently blinded outcome assessors. All other domains were of varying degrees of risk of bias. The quality of evidence was downgraded for lack of blinding in studies and other limitations in study designs, inconsistency, or imprecision of effect estimates.

AUTHORS' CONCLUSIONS

Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support. Subgroup analyses should be interpreted with caution, and considered as exploratory and hypothesis-generating, but evidence suggests continuous support with certain provider characteristics, in settings where epidural analgesia was not routinely available, in settings where women were not permitted to have companions of their choosing in labour, and in middle-income country settings, may have a favourable impact on outcomes such as caesarean birth. Future research on continuous support during labour could focus on longer-term outcomes (breastfeeding, mother-infant interactions, postpartum depression, self-esteem, difficulty mothering) and include more woman-centred outcomes in low-income settings.

Perceived Safety, Quality and Cultural Competency of Maternity Care for Culturally and Linguistically Diverse Women in Queensland

Various policies, plans and initiatives have been implemented to provide safe, quality and culturally competent care to patients within Queensland's health care system. A series of models of maternity care are available in Queensland that range from standard public care to private midwifery care. The current study aimed to determine whether identifying as culturally or linguistically diverse (CALD) was associated with the perceived safety, quality and cultural competency of maternity care from a consumer perspective, and to identify specific needs and preferences of CALD maternity care consumers. Secondary analysis of data collected in the Having a Baby in Queensland Survey 2012 was used to compare the experiences of 655 CALD women to those of 4049 non-CALD women in Queensland, Australia, across three stages of maternity care: pregnancy, labour and birth, and after birth. After adjustment for model of maternity care received and socio-demographic characteristics, CALD women were significantly more likely than non-CALD women to experience suboptimal staff technical competence in pregnancy, overall perceived safety in pregnancy and labour/birth, and interpersonal sensitivity in pregnancy and labour/birth. Approximately 50 % of CALD women did not have the choice to use a translator or interpreter, or the gender of their care provider, during labour and birth. Thirteen themes of preferences and needs of CALD maternity care consumers based on ethnicity, cultural beliefs, or traditions were identified; however, these were rarely met. Findings imply that CALD women in Queensland experience disadvantageous maternity care with regards to perceived staff technical competence, safety, and interpersonal sensitivity, and receive care that lacks cultural competence. Improved access to support persons, continuity and choice of carer, and staff availability and training is recommended.

Effects of continuous midwifery labour support for women with severe fear of childbirth

BACKGROUND

Continuous support by a midwife during childbirth has shown positive effects on the duration of active labour, use of pain relief and frequency of caesarean section (CS) in women without fear of childbirth (FOC). We have evaluated how continuous support by a specially assigned midwife during childbirth affects birth outcome and the subjective experience of women with severe FOC.

METHODS

A case-control pilot study with an index group of 14 women with severe FOC and a reference group of 28 women without FOC giving birth. In this study the index group received continuous support during childbirth.

RESULTS

The women with severe FOC more often had an induction of labour. The parous women with severe FOC had a shorter duration of active labour compared to the parous reference women (p = 0.047). There was no difference in caesarean section frequency between the two groups. Women with severe FOC experienced a very high anxiety level during childbirth (OR = 20.000, 95% CI: 3.036-131.731).

CONCLUSION

Women with severe FOC might benefit from continuous support by a midwife during childbirth. Midwives should acknowledge the importance of continuous support in order to enhance the experience of childbirth in women with severe FOC.

The quality of childbirth care in China: women's voices: a qualitative study

BACKGROUND

In the context of improved utilisation of health care and outcomes, rapid socio-economic development and health system reform in China, it is timely to consider the quality of services. Data on quality of maternal health care as experienced by women is limited. This study explores women's expectations and experiences of the quality of childbirth care in rural China.

METHODS

Thirty five semi-structured interviews and five focus group discussions were conducted with 69 women who had delivered in the past 12 months in hospitals in a rural County in Anhui Province. Data were transcribed, translated and analysed using the framework approach.

RESULTS

Hospital delivery was preferred because it was considered safe. Home delivery was uncommon and unsupported by the health system. Expectations such as having skilled providers and privacy during childbirth were met. However, most women reported lack of cleanliness, companionship during labour, pain relief, and opportunity to participate in decision making as poor aspects of care. Absence of pain relief is one reason why women may opt for a caesarean section.

CONCLUSIONS

These findings illustrate that to improve quality of care it is crucial to build accountability and communication between providers, women and their families. Ensuring women's participation in decision making needs to be addressed.

How Do Women with an Intellectual Disability Experience the Support of a Doula During Their Pregnancy, Childbirth and After the Birth of Their Child?

BACKGROUND

With increasing numbers of people with an intellectual disability choosing to become parents, the right support is imperative for effective parenting (Macintyre & Stewart ). The aim of this study was to gain insight into the experiences of parents who received support from Doulas during pregnancy, birth and following the birth of their child. In addition, the experiences of the Doulas who provided the support were investigated.

MATERIALS AND METHODS

Four women with an intellectual disability who received Doula support were interviewed before and after the birth of their child. Three Doulas were interviewed after the birth about their experiences of supporting women with an intellectual disability.

RESULTS

Interview transcripts were analysed using Interpretive Phenomenological Analysis (IPA). Themes were identified from each interview, before an overall analysis of themes from each support phase was undertaken.

CONCLUSIONS

Pre-natally, the Doula was considered helpful and a reliable source of information about pregnancy. Each mother perceived Doula support as a means of keeping her child in her care. Post-natally, mothers described a trusting relationship with their Doula, who enabled them to make informed choices. Doulas described how they adapted their work to meet the needs of parents with intellectual disability. Being involved in Child Protection procedures was perceived as stressful and challenging.

Birth setting, transfer and maternal sense of control: results from the DELIVER study

BACKGROUND

In the Netherlands, low risk women receive midwife-led care and can choose to give birth at home or in hospital. There is concern that transfer of care during labour from midwife-led care to an obstetrician-led unit leads to negative birth experiences, in particular among those with planned home birth. In this study we compared sense of control, which is a major attribute of the childbirth experience, for women planning home compared to women planning hospital birth under midwife-led care. In particular, we studied sense of control among women who were transferred to obstetric-led care during labour according to planned place of birth: home versus hospital.

METHODS

We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Sense of control during labour was assessed 6 weeks after birth, using the short version of the Labour Agentry Scale (LAS-11). A higher LAS-11 score indicates a higher feeling of control. We considered a difference of a minimum of 5.5 points as clinically relevant.

RESULTS

Nulliparous- and parous women who planned a home birth had a 2.6 (95% CI 1.0, 4.3) and a 3.0 (1.6, 4.4) higher LAS score during first stage of labour respectively and during second stage a higher score of 2.8 (0.9, 4.7) and 2.3 (0.6, 4.0), compared with women who planned a hospital birth. Overall, women who were transferred experienced a lower sense of control than women who were not transferred. Parous women who planned a home birth and who were transferred had a 4.3 (0.2, 8.4) higher LAS score in 2nd stage, compared to those who planned a hospital birth and who were transferred.

CONCLUSION

We found no clinically relevant differences in feelings of control among women who planned a home or hospital birth. Transfer of care during labour lowered feelings of control, but feelings of control were similar for transferred women who planned a home or hospital birth.As far as their expected sense of control is concerned, low risk women should be encouraged to give birth at the location of their preference.

Being safe practitioners and safe mothers: a critical ethnography of continuity of care midwifery in Australia

OBJECTIVE

To examine how midwives and women within a continuity of care midwifery programme in Australia conceptualised childbirth risk and the influences of these conceptualisations on women's choices and midwives' practice.

DESIGN AND SETTING

A critical ethnography within a community-based continuity of midwifery care programme, including semi-structured interviews and the observation of sequential antenatal appointments.

PARTICIPANTS

Eight midwives, an obstetrician and 17 women.

FINDINGS

The midwives assumed a risk-negotiator role in order to mediate relationships between women and hospital-based maternity staff. The role of risk-negotiator relied profoundly on the trust engendered in their relationships with women. Trust within the mother-midwife relationship furthermore acted as a catalyst for complex processes of identity work which, in turn, allowed midwives to manipulate existing obstetric risk hierarchies and effectively re-order risk conceptualisations. In establishing and maintaining identities of 'safe practitioner' and 'safe mother', greater scope for the negotiation of normal within a context of obstetric risk was achieved.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The effects of obstetric risk practices can be mitigated when trust within the mother-midwife relationship acts as a catalyst for identity work and supports the midwife's role as a risk-negotiator. The achievement of mutual identity-work through the midwives' role as risk-negotiator can contribute to improved outcomes for women receiving continuity of care. However, midwives needed to perform the role of risk-negotiator while simultaneously negotiating their professional credibility in a setting that construed their practice as risky.

Adverse outcomes in maternity care for women with a low risk profile in The Netherlands: a case series analysis

BACKGROUND

This study aimed to perform a structural analysis of determinants of risk of critical incidents in care for women with a low risk profile at the start of pregnancy with a view on improving patient safety.

METHODS

We included 71 critical incidents in primary midwifery care and subsequent hospital care in case of referral after 36 weeks of pregnancy that were related to substandard care and for that reason were reported to the Health Care Inspectorate in The Netherlands in 36 months (n = 357). We performed a case-by-case analysis, using a previously validated instrument which covered five broad domains: healthcare organization, communication between healthcare providers, patient risk factors, clinical management, and clinical outcomes.

RESULTS

Determinants that were associated with risk concerned healthcare organization (n = 20 incidents), communication about treatment procedures (n = 39), referral processes (n = 19), risk assessment by telephone triage (n = 10), and clinical management in an out of hours setting (n = 19). The 71 critical incidents included three cases of maternal death, eight cases of severe maternal morbidity, 42 perinatal deaths and 12 critical incidents with severe morbidity for the child. Suboptimal prenatal risk assessment, a delay in availability of health care providers in urgent situations, miscommunication about treatment between care providers, and miscommunication with patients in situations with a language barrier were associated with safety risks.

CONCLUSIONS

Systematic analysis of critical incidents improves insight in determinants of safety risk. The wide variety of determinants of risk of critical incidents implies that there is no single intervention to improve patient safety in the care for pregnant women with initially a low risk profile.

Psychometric assessment of the Health Care Alliance Questionnaire with women in prenatal care

The current study assessed the reliability and validity of the Health Care Alliance Questionnaire, which was developed using a Delphi process and embedded in an ongoing perinatal outcomes study. The Health Care Alliance Questionnaire exhibited content and face validity and high reliability. Results indicated concurrent validity in relation to satisfaction with practitioner and discriminant validity in relation to interpersonal sensitivity and posttraumatic stress disorder. The Health Care Alliance Questionnaire demonstrated predictive validity in relation to perceptions of practitioner's care during labor and postpartum depression. Overall, results suggest that alliance may be an important factor in maternity care processes and outcomes. Further psychometric work is warranted.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013).

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012).

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Continuing education module: finding the path

In this guest editorial, the challenges and pain of childbirth are presented as essential components of important life transitions. The role of pain in childbirth is explored. Childbirth is discussed as a "flow experience," and recommendations for assisting women to meet the challenges of labor and birth are presented.

Nursing support of laboring women. An official position statement of the Association of Women's Health, Obstetric & Neonatal Nursing

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) asserts that continuously available labor support from a registered nurse (RN) is a critical component to achieve improved birth outcomes. The RN assesses, develops,implements and evaluates an individualized plan of care based on each woman's physical,psychological and socio-cultural needs, including the woman's desires for and expectations of the laboring process. Labor care and labor support are powerful nursing functions, and it is incumbent on health care facilities to provide an environment that encourages the unique patient-RN relationship during childbirth.

Patient safety in midwifery-led care in the Netherlands

OBJECTIVE

to describe the incidence and characteristics of patient safety incidents in midwifery-led care for low-risk pregnant women.

DESIGN

multi-method study.

SETTING

20 midwifery practices in the Netherlands; 1,000 patient records.

POPULATION

low-risk pregnant women.

METHODS

prospective incident reporting by midwives during 2 weeks; questionnaire on safety culture and retrospective content analysis of 1,000 patient records in 2009.

MAIN OUTCOME MEASURES

incidence, type, impact and causes of safety incidents.

RESULTS

in the 1,000 patient records involving 14,888 contacts, 86 safety incidents were found with 25 of these having a noticeable effect on the patient. Low-risk pregnant women in midwifery care had a probability of 8.6% for a safety incident (95% CI 4.8-14.4). In 9 safety incidents, temporary monitoring of the mother and/or child was necessary. In another 6 safety incidents, reviewers reported psychological distress for the patient. Hospital admission followed from 1 incident. No safety incidents were associated with mortality or permanent harm. The majority of incidents found in the patient records concerned treatment and organisational factors.

CONCLUSIONS

a low prevalence of patient safety incidents was found in midwifery care for low-risk pregnant women. This first systematic study of patient safety in midwifery adds to the base of evidence regarding the safety of midwifery-led care for low-risk women. Nevertheless, some areas for improvement were found. Improvement of patient safety should address the better adherence to practice guidelines for patient risk assessment, better implementation of interventions for known lifestyle risk factors and better availability of midwives during birthing care.

Active versus expectant management for women in the third stage of labour

BACKGROUND

Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries.

OBJECTIVES

To compare the effectiveness of active versus expectant management of the third stage of labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (15 February 2011).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We included seven studies (involving 8247 women), all undertaken in hospitals, six in high-income countries and one in a low-income country. Four studies compared active versus expectant management, and three compared active versus a mixture of managements. We used random-effects in the analyses because of clinical heterogeneity. There was an absence of high quality evidence for our primary outcomes. The evidence suggested that for women at mixed levels of risk of bleeding, active management showed a reduction in the average risk of maternal primary haemorrhage at time of birth (more than 1000 mL) (average risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin (Hb) less than 9 g/dL following birth (average RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women). We also found no difference in the incidence in admission of infants to neonatal units (average RR 0.81, 95% CI 0.60 to 1.11, two studies, 3207 women) nor in the incidence of infant jaundice requiring treatment (0.96, 95% CI 0.55 to 1.68, two studies, 3142 women). There were no data on our other primary outcomes of very severe postpartum haemorrhage (PPH) at the time of birth (more than 2500 mL), maternal mortality, or neonatal polycythaemia needing treatment.Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion.In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours).Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here.

AUTHORS' CONCLUSIONS

Although there is a lack of high quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.

The Role of Demand Factors in Utilization of Professional Care during Childbirth: Perspectives from Yemen

Background. Utilization of professional care during childbirth by women in low-income countries is important for the progress towards MDG 5. In Yemen, home births have decreased minimally during the past decades. Objective. The study investigates the influence of socio-demographic, birth outcome and demand factors on women's future preference of a home or institutional childbirth. Method. We interviewed 220 women with childbirth experience in urban/rural Yemen. We performed bivariate chi-square tests and multiple logistic regression analysis. A multistage sampling process was used. Results. The issues of own choice, birth support and birth complications were the most important for women's preference of future location of childbirth. Women who had previously been able to follow their own individual choice regarding birth attendance and/or location of childbirth were six times more likely to plan a future childbirth in the same location and women who received birth support four times more likely. Birth complications were associated with a 2.5-fold decrease in likelihood. Conclusions. To offer women with institutional childbirth access to birth support is crucial in attracting women to professional care during childbirth. Yemeni women's low utilization of modern delivery care should be seen in the context of women's low autonomy and status.

The growth of a culture of evidence-based obstetrics in South Africa: a qualitative case study

BACKGROUND

While the past two decades have seen a shift towards evidence-based obstetrics and midwifery, the process through which a culture of evidence-based practice develops and is sustained within particular fields of clinical practice has not been well documented, particularly in LMICs (low- and middle-income countries). Forming part of a broader qualitative study of evidence-based policy making, this paper describes the development of a culture of evidence-based practice amongst maternal health policy makers and senior academic obstetricians in South Africa.

METHODS

A qualitative case-study approach was used. This included a literature review, a policy document review, a timeline of key events and the collection and analysis of 15 interviews with policy makers and academic clinicians involved in these policy processes and sampled using a purposive approach. The data was analysed thematically.

RESULTS

The concept of evidence-based medicine became embedded in South African academic obstetrics at a very early stage in relation to the development of the concept internationally. The diffusion of this concept into local academic obstetrics was facilitated by contact and exchange between local academic obstetricians, opinion leaders in international research and structures promoting evidence-based practice. Furthermore the growing acceptance of the concept was stimulated locally through the use of existing professional networks and meetings to share ideas and the contribution of local researchers to building the evidence base for obstetrics both locally and internationally. As a testimony to the extent of the diffusion of evidence-based medicine, South Africa has strongly evidence-based policies for maternal health.

CONCLUSION

This case study shows that the combined efforts of local and international researchers can create a culture of evidence-based medicine within one country. It also shows that doing so required time and perseverance from international researchers combined with a readiness by local researchers to receive and actively promote the practice.

Continuous support for women during childbirth

BACKGROUND

Historically, women have been attended and supported by other women during labour. However in hospitals worldwide, continuous support during labour has become the exception rather than the routine.

OBJECTIVES

Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010).

SELECTION CRITERIA

All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

DATA COLLECTION AND ANALYSIS

We used standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group. Two authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the risk ratio for categorical data and mean difference for continuous data.

MAIN RESULTS

Twenty-one trials involving 15061 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% CI 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.97) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition their labours were shorter (mean difference -0.58 hours, 95% CI -0.86 to -0.30), they were less likely to have a caesarean (RR 0.79, 95% CI 0.67 to 0.92) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.84 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low 5-minute Apgar score (fixed-effect, RR 0.70, 95% CI 0.50 to 0.96). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeeding. Subgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support.

AUTHORS' CONCLUSIONS

Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

The Evidence for Physiologic Management of the Active Phase of the First Stage of Labor

The active phase of first stage labor is generally defined as the period between 3 cm to 4 cm to complete cervical dilatation, in the presence of regular uterine contractions. Most women will experience this portion of labor within hospital obstetric units, where care commonly features restriction to bed, electronic fetal monitoring, early treatment of "slow" labors, and few pain management options beyond epidurals and narcotics. However, the available evidence on appropriate care for healthy childbearing women favors activity in labor, intermittent auscultation, patience from caregivers, and nonpharmacologic methods of pain relief. This article reviews the evidence for care practices that support physiologic labor. Modifying intrapartum care to reflect current evidence will improve women's health, and will require a multilevel approach and consistent midwifery demonstration of the model.

Choice of instruments for assisted vaginal delivery

BACKGROUND

Instrumental or assisted vaginal birth is commonly used to expedite birth for the benefit of either mother or baby or both. It is sometimes associated with significant complications for both mother and baby. The choice of instrument may be influenced by clinical circumstances, operator choice and availability of specific instruments.

OBJECTIVES

To evaluate different instruments in terms of achieving a vaginal birth and avoiding significant morbidity for mother and baby.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).

SELECTION CRITERIA

Randomised controlled trials of assisted vaginal delivery using different instruments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted the data, and checked them for accuracy.

MAIN RESULTS

We included 32 studies (6597 women) in this review. Forceps were less likely than the ventouse to fail to achieve a vaginal birth with the allocated instrument (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.45 to 0.94). However, with forceps there was a trend to more caesarean sections, and significantly more third- or fourth-degree tears (with or without episiotomy), vaginal trauma, use of general anaesthesia, and flatus incontinence or altered continence. Facial injury was more likely with forceps (RR 5.10, 95% CI 1.12 to 23.25). Using a random-effects model because of heterogeneity between studies, there was a trend towards fewer cases of cephalhaematoma with forceps (average RR 0.64, 95% CI 0.37 to 1.11).Among different types of ventouse, the metal cup was more likely to result in a successful vaginal birth than the soft cup, with more cases of scalp injury and cephalhaematoma. The hand-held ventouse was associated with more failures than the metal ventouse, and a trend to fewer than the soft ventouse.Overall forceps or the metal cup appear to be most effective at achieving a vaginal birth, but with increased risk of maternal trauma with forceps and neonatal trauma with the metal cup.

AUTHORS' CONCLUSIONS

There is a recognised place for forceps and all types of ventouse in clinical practice. The role of operator training with any choice of instrument must be emphasised. The increasing risks of failed delivery with the chosen instrument from forceps to metal cup to hand-held to soft cup vacuum, and trade-offs between risks of maternal and neonatal trauma identified in this review need to be considered when choosing an instrument.

After praise and encouragement: emotional support strategies used by birth doulas in the USA and Canada

OBJECTIVE

to describe in detail the emotional support techniques employed by birth doulas during labour.

DESIGN

grounded theory methodology was utilised in collecting and analysing interviews given by doulas and mothers who had doula care. By using both informants, a clearer picture of what constitutes emotional support by doulas emerged.

PARTICIPANTS

10 mothers from three different states in the Midwestern USA and 30 doulas from 10 different states and two Canadian provinces were interviewed. Two doulas worked in hospital-based programmes whereas the others had independent practices. Doulas usually attended births in hospitals where medical attendants spent little focused time with the mother.

FINDINGS

nine different strategies were distinguished. Four strategies (reassurance, encouragement, praise, explaining) were similar to those attributed to nurses in published research. Five were original and described as only being used by doulas (mirroring, acceptance, reinforcing, reframing, debriefing).

CONCLUSIONS

emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour.

IMPLICATIONS FOR PRACTICE

the doula's role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive 'doula effect' on obstetric and neonatal outcomes in certain settings.

Active versus expectant management for women in the third stage of labour

BACKGROUND

Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping and controlled cord traction to deliver the placenta. With expectant management, signs of placental separation are awaited and the placenta is delivered spontaneously. Active management was introduced to try to reduce haemorrhage, a major contributor to maternal mortality in low-income countries.

OBJECTIVES

To compare the effectiveness of active versus expectant management of the third stage of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing active versus expectant management of the third stage of labour.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We included five studies (6486 women), all undertaken in hospitals in high-income countries. Four compared active versus expectant management, and one compared active versus a mixture of managements. Analysis used random-effects because of clinical heterogeneity. Active management reduced the average risk of maternal primary haemorrhage (more than 1000 ml) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.14 to 0.87, three studies, 4636 women) and of maternal haemoglobin less than 9 g/dl following birth (RR 0.50, 95% CI 0.30 to 0.83, two studies, 1572 women) for women irrespective of their risk of bleeding. We identified no difference in Apgar scores less than seven at five minutes. Active management showed significant increases in maternal diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. There were similar findings for women at low risk of bleeding except there was no significant difference identified for severe haemorrhage. Hypertension and interference with placental transfusion might be avoided by using modifications to the active management package, e.g. omitting ergot and deferring cord clamping, but we have no direct evidence of this here.

AUTHORS' CONCLUSIONS

Active management of third stage reduced the risk of haemorrhage greater than 1000 ml in an unselected population, but adverse effects are identified. Women should be given information on the benefits and harms to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third stage management. Data are also required from low-income countries.

Therapeutic alliance: a concept for the childbearing season

This analysis was conducted to describe the concept of therapeutic alliance and its appropriateness for health-care provider-client interactions during the childbearing season. The concept has been defined in other disciplines. A universal definition suggested a merging of efforts directed toward health. A simple and concise definition evolved, which is applicable to the childbearing season as well as to health-care encounters across the life span. This definition states: Therapeutic alliance is a process within a health-care provider-client interaction that is initiated by an identified need for positive client health-care behaviors, whereby both parties work together toward this goal with consideration of the client's current health status and developmental stage within the life span.

Assisting informed decision making for labour analgesia: a randomised controlled trial of a decision aid for labour analgesia versus a pamphlet

BACKGROUND

Most women use some method of pain relief during labour. There is extensive research evidence available of pharmacological pain relief during labour; however this evidence is not readily available to pregnant women. Decision aids are tools that present evidence based information and allow preference elicitation.

METHODS

We developed a labour analgesia decision aid. Using a RCT design women either received a decision aid or a pamphlet. Eligible women were primiparous, > or = 37 weeks, planning a vaginal birth of a single infant and had sufficient English to complete the trial materials. We used a combination of affective (anxiety, satisfaction and participation in decision-making) and behavioural outcomes (intention and analgesia use) to assess the impact of the decision aid, which were assessed before labour.

RESULTS

596 women were randomised (395 decision aid group, 201 pamphlet group). There were significant differences in knowledge scores between the decision aid group and the pamphlet group (mean difference 8.6, 95% CI 3.70, 13.40). There were no differences between decisional conflict scores (mean difference -0.99 (95% CI -3.07, 1.07), or anxiety (mean difference 0.3, 95% CI -2.15, 1.50). The decision aid group were significantly more likely to consider their care providers opinion (RR 1.28 95%CI 0.64, 0.95). There were no differences in analgesia use and poor follow through between antenatal analgesia intentions and use.

CONCLUSIONS

This decision aid improves women's labour analgesia knowledge without increasing anxiety. Significantly, the decision aid group were more informed of labour analgesia options, and considered the opinion of their care providers more often when making their analgesia decisions, thus improving informed decision making.

TRIAL REGISTRATION

Trial registration no: ISRCTN52287533.

Support during labour: first-time fathers' descriptions of requested and received support during the birth of their child

OBJECTIVE

to explore how first-time fathers describe requested and received support during a normal birth.

DESIGN

qualitative research design. Ten first-time fathers were interviewed during the first postpartum week. Individual open-ended interviews were used to explore the fathers' descriptions, and the interviews were analysed using qualitative analysis.

SETTING

a labour ward at one hospital in a south-western county of Sweden in November and December 2006.

PARTICIPANTS

first-time fathers who had experienced a normal birth at the hospital during the study period.

FINDINGS

the support described is presented as one main theme, 'being involved or being left out', which included four underlying categories: 'an allowing atmosphere', 'balancing involvement', 'being seen' and 'feeling left out'.

KEY CONCLUSIONS

fathers perceived that they were given good support when they were allowed to ask questions during labour, when they had the opportunity to interact with the midwife and their partner, and when they could choose when to be involved or to step back. Fathers want to be seen as individuals who are part of the labouring couple. If fathers are left out, they tend to feel helpless; this can result in a feeling of panic and can put their supportive role of their partner at risk.

IMPLICATIONS FOR PRACTICE

the results of this study could initiate discussions about how health-care professionals can develop support given to the labouring couple, with an interest in increasing paternal involvement.

Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial

OBJECTIVE

To assess the effect of psychosocial support on labour outcomes.

METHODOLOGY

A randomised control trial conducted at the University College Hospital Ibadan, Nigeria, from November 2006 to 30 March 2007. Women with anticipated vaginal delivery were recruited and randomised at the antenatal clinic. The experimental group had companionship in addition to routine care throughout labour until two hours after delivery, while the controls had only routine care. The primary outcome measure was caesarean section rate. Others included duration of active phase, pain score, time of breast-feeding initiation and description of labour experience. Multivariable analyses were used to adjust for potential confounders. The level of statistical significance was set at 5%.

RESULTS

Of the 632 recruited, 585 were eventually studied: 293 and 292 were in experimental and control groups, respectively. Husbands constituted about two-thirds of the companions. Women in the control group were about five times more likely to deliver by caesarean section (95% confidence interval (CI) 1.98-12.05), had significantly longer duration of active phase (P < 0.001), higher pain scores (P = 0.011) and longer interval between delivery and initiation of breast-feeding (P < 0.001). However, those in experimental group had a more satisfying labour experience (odds ratio 3.3 95% CI 2.15-5.04).

CONCLUSION

Women with companionship had better labour outcomes compared to those without. It is desirable to adopt this practice in our health-care settings as an alternative strategy to provide comparable quality services to would-be mothers in labour.