Linking obstetric and midwifery practice with optimal outcomes

Midwifery practice in Mongolia: Policy implications for accelerating care delivery transformation

Midwives can play a significant role in reducing maternal and neonatal mortality rates as well as in improving maternal and perinatal health outcomes in low- and middle-income countries such as Mongolia. However, the shortage of midwives in Mongolia is severe. Despite the evidence indicating numerous challenges associated with substandard midwifery education and practice in Mongolia, there is a need for policy recommendations to accelerate the improvement of midwifery care delivery in the country. Therefore, we identified three main topics as key issues in Mongolian midwifery care: 1) the current training and service delivery in midwifery; 2) the potential for the development of the midwifery role; and 3) content requirements for the postgraduate certificate in midwifery. The World Health Organization report made forty recommendations to enhance the midwife's role to professional status. However, the absence of senior nursing/midwifery leadership in the Ministry of Health in Mongolia has hindered the implementation of the recommendations. To strengthen midwifery at a national level, it is imperative to make multilevel investments in supporting educators and clinical practitioners to ensure the delivery of high-quality midwifery care. This article represents an initial in-depth exploration of issues in Mongolian midwifery practice, with the aim of providing suggestions for practical avenues for enhancing midwifery care in Mongolia.

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Midwifery-led care is an evidence-based practice in which a qualified midwife provides comprehensive care for low-risk pregnant women and new-borns throughout pregnancy, birth, and the postnatal period. Evidence indicates that midwifery-led care has positive impacts on various outcomes, which include preventing preterm births, reducing the need for interventions, and improving clinical outcomes. This is, however, mainly based on studies from high-income countries. Therefore, this systematic review and meta-analysis aimed to assess the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.

METHODS

We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Three electronic databases (PubMed, CINAHL, and EMBASE) were searched. The search results were systematically screened by two independent researchers. Two authors independently extracted all relevant data using a structured data extraction format. Data analysis for the meta-analysis was done using STATA Version 16 software. A weighted inverse variance random-effects model was used to estimate the effectiveness of midwifery-led care on pregnancy outcomes. Odds ratio with a 95% confidence interval (CI) was presented using a forest plot.

RESULTS

Ten studies were eligible for inclusion in this systematic review, of which five studies were eligible for inclusion in the meta-analysis. Women receiving midwifery-led care had a significantly lower rate of postpartum haemorrhage and a reduced rate of birth asphyxia. The meta-analysis further showed a significantly reduced risk of emergency Caesarean section (OR = 0.49; 95% CI: 0.27-0.72), increased odds of vaginal birth (OR = 1.14; 95% CI: 1.04-1.23), decreased use of episiotomy (OR = 0.46; 95% CI: 0.10-0.82), and decreased average neonatal admission time in neonatal intensive care unit (OR = 0.59; 95% CI: 0.44-0.75).

CONCLUSIONS

This systematic review indicated that midwifery-led care has a significant positive impact on improving various maternal and neonatal outcomes in low- and middle-income countries. We therefore advise widespread implementation of midwifery-led care in low- and middle-income countries.

Midwife-led continuity of care improved maternal and neonatal health outcomes in north Shoa zone, Amhara regional state, Ethiopia: A quasi-experimental study

BACKGROUND

In a low-resource setting, information on the effect of midwife-led continuity of care (MLCC) is limited. Therefore, this study aimed to determine the effect of MLCC on maternal and neonatal health outcomes in the Ethiopian context.

METHOD

A study with a quasi-experimental design was conducted from August 2019 to September 2020 in four primary hospitals of the north Shoa zone, Amhara regional state, Ethiopia. A total of 1178 low risk women were allocated to one of two groups; the midwife-led continuity of care (MLCC or intervention group) (received all antenatal, labour, birth, and immediate postnatal care from a single midwife or backup midwife) (n = 589) and the Shared model of care (SMC or comparison group) (received care from different staff members at different times) (n = 589). The two outcomes studied were Spontaneous vaginal birth and preterm birth. Outcome variables were compared using multivariate generalized linear models (GLMs) and reported using adjusted risk ratios (aRR) with 95% confidence intervals.

FINDINGS

Women in MLCC were, in comparison with women in the SMC group more likely to have spontaneous vaginal birth (aRR of 1.198 (95% CI 1.101-1.303)). Neonates of women in MLCC were in comparison with those in SMC less likely to be preterm (aRR of 0.394; 95% CI (0.227-0.683)).

CONCLUSION

In this study, use of the MLCC model improved maternal and neonatal health outcomes. To scale up and further investigate the effect and feasibility of this model in a low resource setting could be of considerable importance in Ethiopia and other Sub-Saharan Africa countries.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

BACKGROUND

Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia.

METHODS

The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor.

RESULTS

In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC.

CONCLUSION

This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

Variables related to maternal satisfaction with intrapartum care in Northern Italy

BACKGROUND

The experience of labour and birth is complex, multidimensional and subjective and has the potential to affect the women and their families physically and emotionally. However, there is a lack of research around maternal satisfaction in Italy.

AIM

To evaluate mothers' satisfaction with their childbirth experience in relation to socio-demographic characteristics, obstetric history and intrapartum care variables.

METHODS

A cross-sectional study involving 277 women who had given birth in a low risk maternity unit in Northern Italy was undertaken. Satisfaction with birth was measured using the Italian version of the Birth Satisfaction Scale-Revised (I-BSS-R). The scale comprises three Sub-Scales: quality of care provided, personal attributes of women and stress experienced during childbirth.

FINDINGS

No socio-demographic variables were related to maternal satisfaction. Multiparous women had a higher satisfaction score (p=0.020; CI:0.23;2.75). Antenatal class attendance was negatively associated with maternal satisfaction (p=0.038; CI:-2.58; -0.07). Intrapartum variables that significantly reduced maternal satisfaction were: epidural usage (p=0.000; CI:-4.66; -2.07), active phase >12h (p=0.000; CI:-6.01; -2.63), oxytocin administration (p=0.000; CI:-5.08; -2.29) and vacuum assisted birth (p=0.001; CI:-6.50; -1.58). Women with an intact perineum were more likely to be satisfied (p=0.008; CI:-4.60; -0.69).

DISCUSSION

In accordance with other research, we showed that intrapartum interventions are negatively associated with maternal outcomes and therefore also with maternal satisfaction with birth. The sub-scale that measured Quality of Care provided scored higher than the other two Sub-Scales.

CONCLUSION

Further studies on maternal satisfaction in Italy should be conducted, using the I-BSS-R with the aim to compare outcomes and understand what matters to women during childbirth.

The experiences of midwives in integrated maternity care: A qualitative metasynthesis

OBJECTIVES

To conduct a metasynthesis of eight qualitative studies of the experiences of midwives in integrated maternity practice; to identify common motifs among the eight studies through a thematic interpretive integration known as reciprocal translation; and to explore the effects on midwifery processes of care in the setting of integrated maternity practice.

DESIGN

A qualitative metasynthesis to analyze, synthesize, and interpret eight qualitative studies on the experiences of midwives and the effect on the midwifery processes of care in the setting of integrated maternity practice.

SAMPLE AND SETTING

Participants from the primary studies included a total of 160 midwives providing hospital-based intrapartum care. All primary studies were conducted in settings with midwives and obstetricians working together in an integrated or collaborative manner.

FINDINGS

Three overarching themes emerged from the data: professional dissonance, functioning from a position of risk, and practicing down.

KEY CONCLUSIONS

The findings indicated that integrated maternity practice affects the professional experience of midwives. Through a qualitative exploration, a clear process of deprofessionalization and deviation from the midwifery model of care is detailed. Midwives experienced decreasing opportunity to provide the quality woman-centered physiologic care that evidence shows benefits childbearing women.

IMPLICATIONS FOR PRACTICE

Integrated maternity practice, where low-risk and high-risk pregnancies are managed by midwife/physician teams, have proliferated as a solution to the need for quality, safe, and efficient health care. Insufficient evidence exists detailing the success or failure of this model of care. Qualitative studies suggest that the increasing medicalization occurring in integrated maternity practices minimizes the profession of midwifery and the ability to provide evidence-based quality midwifery care.

Ethnographic study of the use of interventions during the second stage of labor in Jeddah, Saudi Arabia

BACKGROUND

Routine use of medical interventions during labor has been identified as a clinical area for concern, since such routinized practice is not consistent with an evidence-based approach to care and continues to increase despite efforts to encourage normal childbirth. Therefore, the aim of our study was to explore maternity health professionals' use of interventions during the second stage of labor in two hospitals in Jeddah, Saudi Arabia, to understand what influences their decision-making and practices.

METHODS

This was an exploratory study using an ethnographic approach. Data collection methods included participant observations of 19 labors and births (n = 8 at City Hospital and n = 11 at King's Hospital) and semi-structured interviews with 29 health care professionals. In addition, the hospital labor and delivery ward policies and guidelines from those hospitals were collected. Data were analyzed thematically.

RESULTS

Medical interventions were used during the second stage of labor routinely, regardless of clinical indication. Three core influences that shaped the clinical decision-making were identified as follows: (a) organizational culture, (b) a medical concept of birth, and (c) a hierarchical system of control. We suggest that the clinical decision-making and routine practice in this setting arises out of the interface between these three core influences whereby hierarchical control and clinicians' exercise of power and feelings of powerlessness are fundamental drivers for an organizational culture of medicalized childbirth, despite the differing models of childbirth which professionals described.

CONCLUSIONS

Clinical decisions relating to the use of interventions during childbirth are both complex and socially negotiated. The findings reflect the complexity of the use of interventions during the second stage of labor and the multiple influences on professionals' practices. We have shown how three key influences interact to shape clinical decision-making during the second stage of labor in this cultural setting and how the use of medical interventions can be analyzed as an illustration of the power dynamic in the maternity health care system. We suggest that written policies are insufficient to bring about evidence-based practice and approaches to change need to take into account these different levels of influence.

Women's Health Outpatient Care Teams: Focus on Advanced Practice Providers

Team-based care in the outpatient women's health setting has the potential to help alleviate the demand for women's health care providers and to deliver improved quality of care to the growing population of US women. Although teamwork is necessary in the current health care system, most of the current obstetrics and gynecology and advanced practice provider (APP) workforce were not trained for collaborative practice. Core competencies for building an effective outpatient women's health care team are explained and current evidence regarding the specific role of APPs in women's health care is reviewed.

Competitive effects of scope of practice restrictions: Public health or public harm?

The demand for healthcare professionals is predicted to grow significantly over the next decade. Securing an adequate workforce is of primary importance to ensure the health and wellbeing of the population in an efficient manner. Occupational licensing laws and related restrictions on scope of practice (SOP) are features of the market for healthcare professionals and are also controversial. At issue is a balance between protecting the public health and removing anticompetitive barriers to entry and practice. In this paper, we examine the case of SOP restrictions for certified nurse midwives (CNMs) and evaluate the effects of changes in states' SOP laws on markets for CNMs and on maternal and infant outcomes. We find that SOP laws are neither helpful nor harmful in regards to health outcomes but states that have no SOP-based barriers have lower rates of induced labor and Cesarean section births. We discuss the implications for state policy.

Comparison of midwife-led care and obstetrician-led care on maternal and neonatal outcomes in Singapore: A retrospective cohort study

OBJECTIVES

to examine the maternal and neonatal outcomes of low-risk women receiving midwife-led care and obstetrician-led care. DESIGN, SETTING,&PARTICIPANTS: a retrospective cohort study design was used. Data were collected from a large tertiary maternity hospital in Singapore. This involved a medical record review of 368 women who had singleton, normal to low-risk, term pregnancy, and received midwife-led care and obstetrician-led care between 2013 to 2014.

MEASUREMENTS

a data extraction tool was used to solicit information on the outcome measures, including duration of labour, mode of delivery, episiotomy, and 5-minutes Apgar score (<7). Descriptive statistics were used to summarise the women's 'characteristics. χ² and independent sample t-test were used to assess the differences in demographics and birth outcomes. Multiple linear and logistic regressions were used to examine the difference between the two comparison groups after adjusted for potential confounders.

FINDINGS

statistically significant differences (p<0.05) between the midwife-led care group and the obstetrician-led care group in terms of the total duration of labour and total antenatal visits were found. No statistically significant differences were observed for mode of delivery, episiotomy, intrapartum pain management, labour augmentation, labour induction, postpartum haemorrhage, perineal trauma, birth status, 5-minutes Apgar score (<7), low birth weight (<2500g), and neonatal admission to intensive care units between the midwife-led care group and the obstetrician-led care group.

KEY CONCLUSIONS

while interventions such as episiotomies and labour augmentation were more common in the midwife-led care group, no significant differences were found for most of the outcome measures between the two maternity groups except for total antenatal visits and duration of labour. Findings suggest that midwife-led care is as safe and effective as obstetrician-led care in achieving optimal birth outcomes, with no higher risk of adversities for low-risk women. Additional studies are necessary to continuously evaluate midwife-led care and to promote normal birth and reduce excessive use of obstetric procedures.

IMPLICATIONS FOR PRACTICE

the provision of midwife-led care should continue to be extended as an additional choice in maternity care for women with low-risk pregnancies. Professional staff development with continuous education is needed to clear misconceptions about midwife-led care and to promote awareness in current practice guidelines. Prospective evaluation of midwife-led care will be beneficial in informing policies and practise guidelines.

Critical thinking skills in midwifery practice: Development of a self-assessment tool for students

OBJECTIVE

Develop and test a tool designed for use by pre-registration midwifery students to self-appraise their critical thinking in practice.

DESIGN

A descriptive cohort design was used.

PARTICIPANTS

All students (n=164) enrolled in a three-year Bachelor of Midwifery program in Queensland, Australia.

METHODS

The staged model for tool development involved item generation, mapping draft items to critical thinking concepts and expert review to test content validity, pilot testing of the tool to a convenience sample of students, and psychometric testing. Students (n=126, 76.8% response rate) provided demographic details, completed the new tool, and five questions from the Motivated Strategies for Learning Questionnaire (MSLQ) via an online platform or paper version.

FINDINGS

A high content validity index score of 0.97 was achieved through expert review. Construct validity via factor analysis revealed four factors: seeks information, reflects on practice, facilitates shared decision making, and evaluates practice. The mean total score for the tool was 124.98 (SD=12.58). Total and subscale scores correlated significantly. The scale achieved good internal reliability with a Cronbach's alpha coefficient of 0.92. Concurrent validity with the MSLQ subscale was 0.35 (p<0.001).

CONCLUSION

This study established the reliability and validity of the CACTiM - student version for use by pre-registration midwifery students to self-assess critical thinking in practice.

IMPLICATIONS FOR PRACTICE

Critical thinking skills are vital for safe and effective midwifery practice. Students' assessment of their critical thinking development throughout their pre-registration programme makes these skills explicit, and could guide teaching innovation to address identified deficits. The availability of a reliable and valid tool assists research into the development of critical thinking in education and practice.

The American College of Nurse-Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models

In 2014, the American College of Nurse-Midwives (ACNM) launched a project called Clarity in Collaboration to develop data definitions related to midwifery and maternity care delivery processes. These definitions are needed to ensure midwifery care delivered in collaborative care models is accurately and consistently captured in clinical documentation systems, data registries, and systems being developed as part of health care restructuring and payment reform. The Clarity in Collaboration project builds on the efforts of the Women's Health Registry Alliance (WHRA), which was recently established by the American College of Obstetricians and Gynecologists. Clarity in Collaboration mirrored the process used by ReVITALize, WHRA's first maternity data standardization project, which focused on establishing standardized clinical data definitions for obstetrics. The ACNM Clarity in Collaboration project brought together maternity and midwifery care experts to complete a year-long consensus process, including a period of public comment, resulting in development of 20 concept definitions. These definitions can be used to describe midwifery care within the context of collaborative care models. This article provides a summary of the ACNM Clarity in Collaboration process with discussion of implications for maternity data collection.

Retrospective Review of Nurse-Midwifery Care at a Large University Health System

The purpose of the study is to characterize practice trends, outcomes, and changes over time of a full-scope midwifery service over the past 30 years from 1983 to 2013. The types of clients served and the evolution of the services provided and resulting outcomes are described as an exemplar of the changing nature of providing midwifery services in a tertiary care hospital setting. The overall data reveal that despite small increases in intervention practices, such as epidurals, inductions, and cesarean births, midwives have a commitment to providing safe, evidenced-based, woman-centered care within a collaborative practice model at a tertiary care center. The role of midwives as leaders in supporting physiologic birth in this setting and encouraging opportunities for interprofessional education and collaborative is demonstrated.

Comparison of childbirth care models in public hospitals, Brazil

OBJECTIVE

To compare collaborative and traditional childbirth care models.

METHODS

Cross-sectional study with 655 primiparous women in four public health system hospitals in Belo Horizonte, MG, Southeastern Brazil, in 2011 (333 women for the collaborative model and 322 for the traditional model, including those with induced or premature labor). Data were collected using interviews and medical records. The Chi-square test was used to compare the outcomes and multivariate logistic regression to determine the association between the model and the interventions used.

RESULTS

Paid work and schooling showed significant differences in distribution between the models. Oxytocin (50.2% collaborative model and 65.5% traditional model; p < 0.001), amniotomy (54.3% collaborative model and 65.9% traditional model; p = 0.012) and episiotomy (collaborative model 16.1% and traditional model 85.2%; p < 0.001) were less used in the collaborative model with increased application of non-pharmacological pain relief (85.0% collaborative model and 78.9% traditional model; p = 0.042). The association between the collaborative model and the reduction in the use of oxytocin, artificial rupture of membranes and episiotomy remained after adjustment for confounding. The care model was not associated with complications in newborns or mothers neither with the use of spinal or epidural analgesia.

CONCLUSIONS

The results suggest that collaborative model may reduce interventions performed in labor care with similar perinatal outcomes.

Using the Optimality Index-US to Teach Midwifery Students to Recognize and Implement Evidence-Based Practices That Promote Optimal Outcomes in Perinatal Health

INTRODUCTION

Perinatal optimality means achieving maximal perinatal outcomes with minimal interventions considering women's past and present histories. The Optimality Index-US (OI-US) is a research tool designed to measure potential associations between evidence-based perinatal care processes and outcomes in aggregate groups of women against an optimal standard. This article describes how the Shenandoah University Nurse-Midwifery Program uses the OI-US to teach students to recognize evidence-based care, reflect on the influences that care processes may have on outcomes, and consider the value of measuring the relationship between interventions and outcomes. Case studies and individual presentations apply the optimality concept by illustrating different care processes, identifying evidence-based care, and evaluating management through the optimality lens.

METHODS

A pilot study was performed in which a 10-question interview was administered to 9 midwifery students before graduation. Two research questions were addressed: "Is the OI-US an effective teaching tool?" and "How can the program improve this strategy?" Narrative analysis was used to interpret students' understandings of the tool, how it affected their clinical learning, and its potential to use in future practices.

RESULTS

Four themes were identified: 1) students felt the OI-US gave them a foundation to assess their management and the confidence to plan future management, 2) students used the OI-US as a teaching tool to help women prevent nonoptimal events from occurring, 3) students thought the OI-US would be feasible to use in their future practices, and 4) lack of accessibility to a printed version of the tool while providing care was an obstacle for efficient use. Students suggested increasing the tool's accessibility and using it in other learning activities.

DISCUSSION

The use of the OI-US should be explored further to teach evidence-based care, to generate reflection concerning potential associations between perinatal care processes and outcomes, and to challenge students to question non-evidence-based practices.

Perinatal outcomes of uninsured immigrant, refugee and migrant mothers and newborns living in Toronto, Canada

Canadian healthcare insurance is not universal for all newcomer populations. New immigrant, refugee claimant, and migrant women face various barriers to healthcare due to the lack of public health insurance coverage. This retrospective study explored the relationships between insurance status and various perinatal outcomes. Researchers examined and compared perinatal outcomes for 453 uninsured and provincially insured women who delivered at two general hospitals in the Greater Toronto Area between 2007 and 2010. Data on key perinatal health indicators were collected via chart review of hospital medical records. Comparisons were made with regional statistics and professional guidelines where available. Four-in-five uninsured pregnant women received less-than-adequate prenatal care. More than half of them received clearly inadequate prenatal care, and 6.5% received no prenatal care at all. Insurance status was also related to the type of health care provider, reason for caesarean section, neonatal resuscitation rates, and maternal length of hospital stay. Uninsured mothers experienced a higher percentage of caesarian sections due to abnormal fetal heart rates and required more neonatal resuscitations. No significant difference was found for low birth weight, preterm birth, NCIU admissions, postpartum hemorrhage, breast feeding, or intrapartum care provided.

US nulliparas' perceptions of roles and of the birth experience as predictors of their delivery preferences

OBJECTIVE

to develop a model for understanding predictors of nulliparas' delivery preferences: provider type, setting, mode of delivery and the use/avoidance of pain medication.

DESIGN

a cross-sectional, descriptive, self-administered, web-based survey. The sample was composed of nulliparous women aged 18-40, living in the US and pregnant at 20 or fewer weeks' gestation (n=344). Data were analysed using structural equation modelling.

FINDINGS

women who regard their active participation as effective and essential to the childbearing process are more likely to prefer the care of a midwife, the home as the birth setting, vaginal delivery and the avoidance of pain medication compared to women who see their role as a passive one. When women perceive their provider's role to be more central to the delivery process than their own, they are likely to prefer the care of a physician and the hospital setting. If the provider's role is seen as a collaborative one, women are likelier to prefer midwifery care and planned home birth. The more painful and fearful a woman expects the delivery experience to be, the more likely she is to prefer a caesarean delivery to vaginal birth.

KEY CONCLUSIONS

women's perceptions of (a) their role in pregnancy and delivery, (b) their providers' role in assisting them and (c) the nature of the delivery experience are effective predictors of their delivery preferences.

IMPLICATIONS FOR PRACTICE

providers can help ensure that the informational resources that influence women's perceptions about delivery are factual and evidence-based.

Birthplace: a model of collaborative care at Baystate Franklin Medical Center

Nurse midwives, nurses, and physicians at this facility have lowered rates of medical interventions while giving patients greater say.

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

OBJECTIVE

to pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk.

DESIGN

a multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records.

SETTING

a maternity unit of an inner city teaching hospital in England.

PARTICIPANTS

clinical midwives, research midwives, midwifery lecturers and consultant obstetricians (n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care.

MEASUREMENTS AND FINDINGS

when the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US.

KEY CONCLUSIONS

the following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancy

IMPLICATIONS FOR PRACTICE

availability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparison of background risk and outcomes across a range of care settings.

Use of the Optimality Index-United States in perinatal clinical research: a validation study

The objective of this study was to assess the validity and observed effect size of a new instrument, the Optimality Index-United States (OI-US), for use in perinatal clinical research. Using a large, hospital-based, midwifery service clinical database that included complete obstetric data for 3425 women, we examined discriminant validity and the effects of two different scoring methods used with the OI-US. Discriminant validity was confirmed by comparing OI scores for women who remained low risk and did not require physician involvement in their care (OI score mean = 84%; standard deviation [SD] = 8%) compared to those whose condition changed to require physician involvement in their care (mean = 71%; SD = 10%; P < .001). Two methods of scoring the OI-US were compared, finding no significant difference and suggesting that the types of data available and the research question can drive this decision. Finally, effect size was calculated by two methods: Cohen's d (-1.4) and the effect size correlation (r = -0.548), the latter of which corresponds to a d of -1.3, both resulting in a similarly large effect size estimation. The OI-US is a new instrument that shows promise for use in perinatal clinical research, particularly when assessing more subtle clinical differences in outcomes between study groups.

Observing position and movements in hydrotherapy: a pilot study

OBJECTIVE

To observe and describe the positions and movements women choose while immersed in water during the first stage of labor.

DESIGN

Descriptive, observational pilot study.

SETTING

A rural community hospital that provided hydrotherapy in labor.

PARTICIPANTS

Women (N = 7) who intended to use hydrotherapy in labor were recruited prenatally from a midwife-managed practice.

MEASURES

For 15 minutes of each hour during the first stage of labor, position and movements of the participants were observed and recorded on a laptop computer. The observational tool was developed for this study from a review of the literature and interviews with nursing experts; 435 observations were recorded. Women were free to choose when and how long to use hydrotherapy and had no restriction on their positions and movements.

RESULTS

Only 3 of the 7 participants labored in the tub. Women demonstrated a greater range of positions and movements in the tub than in bed, both throughout labor and during late first-stage labor (7-10 cm of dilatation). Women had more contractions and made more rhythmic movements while in the tub than in bed.

CONCLUSIONS

Hydrotherapy may encourage upright positions and movements that facilitate labor progress and coping, helping women avoid unnecessary interventions.

Reliability of a perinatal outcomes measure: the Optimality Index-US

The Optimality Index-US, a recently developed perinatal clinimetric index, has been validated with both clinical and research databases. Documentation of the reliability of the instrument for medical record abstraction is needed. This paper reports outcomes of interrater reliability assessments conducted for two projects. Abstraction was supervised by the same investigator, but staffed by different coders who had a variety of qualifications (perinatal nurse, nurse-midwife, clinical trial professional, student research assistants). Medical records were entirely paper at one site and partially electronic at another. Reliability (reproducibility) was assessed via percent agreement between pairs of coders on charts randomly selected for audits. Mean percentage agreement was 92.7% in both projects with a range from 89.1% to 97.8% in the first project, and a range from 88.5% to 96.2% in the second project. The sources of error differed between clinician and lay abstractors, but the number of errors did not differ. The average time per chart was assessed in the first project. Once proficiency was achieved, the average time needed to complete coding was 24 minutes, with some additional time needed for ordering paper charts. These analyses indicate that excellent reproducibility can be achieved with the Optimality Index-US.

Development of the Optimality Index as a New Approach to Evaluating Outcomes of Maternity Care

Evaluating perinatal outcomes within a framework of normalcy is a new focus of measurement. As maternal and child health clinicians and researchers look to evaluate care practices that are both of high quality and cost-effective, it is important to have measurement tools that assess differences among all women giving birth. The Optimality Index-US shifts the focus from rare adverse events to evidence-based optimal events. This article describes the continuing development of the index and discusses clinical implications for obstetric nurse clinicians.

A Concept Analysis of Optimality in Perinatal Health

This analysis was conducted to describe the concept of optimality and its appropriateness for perinatal health care. The concept was identified in 24 scientific disciplines. Across all disciplines, the universal definition of optimality is the robust, efficient, and cost-effective achievement of best possible outcomes within a rule-governed framework. Optimality, specifically defined for perinatal health care, is the maximal perinatal outcome with minimal intervention placed against the context of the woman's social, medical, and obstetric history.