Disaster in pregnancy: midwifery continuity positively impacts infant neurodevelopment, QF2011 study

Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study

OBJECTIVE

The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]).

METHODS

2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum.

RESULTS

Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care.

CONCLUSION

Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

Heatwaves and wildfires suffocate our healthy start to life: time to assess impact and take action

Adverse environmental exposures in utero and early childhood are known to programme long-term health. Climate change, by contributing to severe heatwaves, wildfires, and other natural disasters, is plausibly associated with adverse pregnancy outcomes and an increase in the future burden of chronic diseases in both mothers and their babies. In this Personal View, we highlight the limitations of existing evidence, specifically on the effects of severe heatwave and wildfire events, and compounding syndemic events such as the COVID-19 pandemic, on the short-term and long-term physical and mental health of pregnant women and their babies, taking into account the interactions with individual and community vulnerabilities. We highlight a need for an international, interdisciplinary collaborative effort to systematically study the effects of severe climate-related environmental crises on maternal and child health. This will enable informed changes to public health policy and clinical practice necessary to safeguard the health and wellbeing of current and future generations.

Climate Change and Pregnancy: Risks, Mitigation, Adaptation, and Resilience

Importance

Climate change is affecting the earth, resulting in more extreme temperatures and weather, rising sea levels, more frequent natural disasters, and displacement of populations of plants and animals, including people and insects. These changes affect food and housing security, vector-borne illnesses, and access to clean air and water, all of which influence human health.

Evidence and Results

There are a number of adverse health outcomes linked to heat, air pollution from wildfires, stress from natural disasters, and other elements of climate change. Pregnant people are especially vulnerable to the health harms resulting from climate change, namely, preterm birth, small for gestational age, hypertensive disorders of pregnancy, and other adverse reproductive health and birth outcomes. Strategies to minimize these harms include mitigation and adaptation.

Conclusions and Relevance

Physicians are in a unique position to protect the health of pregnant persons and children by advocating for policy changes that address climate change and providing clinical recommendations for patients to protect themselves from the health impacts of climate hazards.

The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature

PROBLEM

Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice.

BACKGROUND

Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences.

AIMS

To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice.

FINDINGS

Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice.Discussion Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system.

CONCLUSIONS

There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.

Newborns' Bonding and Attachment, Their Rhythms and Needs, Supporting Parents Appropriately: Guidelines for Interventions During the Perinatal Period from the French National College Of Midwives

A newborn's sleep-wake rhythms are very specific, neurologically determined, and different from the pattern of adults; they require an adaptable and predictable response by parents, which will promotes bonding and attachments, constructed at the early stages of development. It also will influence the quality of subsequent emotional relationships and adaptation to life events. This parental adaptability should receive multiprofessional support starting in the perinatal period, focused on the screening and management of psychological vulnerability.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service

Background

Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women.

Methods

A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework.

Results

Themes identified were the woman’s experience, midwifery workforce capabilities, identifying “gold standard care”, the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives.

Conclusion

There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08633-8.

Association between severe cyclone events and birth outcomes in Queensland, Australia, 2008-2018: a population based retrospective cohort study

OBJECTIVE

Investigate an association between severe tropical cyclones (TCs) and birth outcomes in an Australian population.

METHODS

We analysed over 600,000 singleton livebirths collected through the Queensland Perinatal Data Collection between 2008 and 2018. We estimated the odds ratios (ORs) of adverse birth outcomes using logistic multi-level modelling.

RESULTS

Exposure to TCs in early pregnancy was associated with significantly higher odds of preterm births in affected compared to unaffected areas during the TC year [OR=1.28, 95%CI=1.11, 1.49, p=0.001] and slightly significant higher odds in affected areas during TC years compared to non-TC years. Significantly higher odds of low birthweight births were associated with mid-pregnancy exposure to cyclone Marcia [OR=1.62, 95%CI=1.00, 2.40, p=0.016] .

CONCLUSIONS

Findings aligned with studies demonstrating an association between exposure to environmental stressors in early to mid-pregnancy and adverse birth outcomes.

IMPLICATIONS FOR PUBLIC HEALTH

There is limited research into TCs and perinatal health in Australia despite most of the population residing along coastlines and TCs presenting one of the nation's most devastating weather events. This study will inform public health practice and contribute to further research into mitigating environmental risks faced by pregnant women.

The Impact of Maternal Prenatal Stress Related to the COVID-19 Pandemic during the First 1000 Days: A Historical Perspective

The COVID-19 pandemic has a major impact on society, particularly affecting its vulnerable members, including pregnant women and their unborn children. Pregnant mothers reported fear of infection, fear of vertical transmission, fear of poor birth and child outcomes, social isolation, uncertainty about their partner's presence during medical appointments and delivery, increased domestic abuse, and other collateral damage, including vaccine hesitancy. Accordingly, pregnant women's known vulnerability for mental health problems has become a concern during the COVID-19 pandemic, also because of the known effects of prenatal stress for the unborn child. The current narrative review provides a historical overview of transgenerational effects of exposure to disasters during pregnancy, and the role of maternal prenatal stress. We place these effects into the perspective of the COVID-19 pandemic. Hereby, we aim to draw attention to the psychological impact of the COVID-19 pandemic on women of reproductive age (15-49 year) and its potential associated short-term and long-term consequences for the health of children who are conceived, carried, and born during this pandemic. Timely detection and intervention during the first 1000 days is essential to reduce the burden of transgenerational effects of the COVID-19 pandemic.

Maternal Mental Health after a Wildfire: Effects of Social Support in the Fort McMurray Wood Buffalo Study

OBJECTIVE

Following disasters, perinatal women are vulnerable to developing post-traumatic stress disorder (PTSD)-like symptoms. Little is known about protective factors. We hypothesized that peritraumatic stress would predict PTSD-like symptoms in pregnant and postpartum women and would be moderated by social support and resilience.

METHOD

Women (n = 200) who experienced the 2016 Fort McMurray Wood Buffalo wildfire during or shortly before pregnancy completed the Peritraumatic Distress Inventory (PDI), Peritraumatic Dissociative Experiences Questionnaire, and the Impact of Event Scale-Revised for current PTSD-like symptoms. They also completed scales of social support (Social Support Questionnaire-Short Form) and resilience (Connor-Davidson Resilience Scale).

RESULTS

Greater peritraumatic distress (r = 0.56) and dissociative experiences (r = 0.56) correlated with more severe PTSD-like symptoms. Greater social support satisfaction was associated with less severe post-traumatic stress symptoms but only when peritraumatic distress was below average; at more severe levels of PDI, this psychosocial variable was not protective.

CONCLUSIONS

Maternal PTSD-like symptoms after a wildfire depend on peritraumatic distress and dissociation. Higher social support satisfaction buffers the association with peritraumatic distress, although not when peritraumatic reactions are severe. Early psychosocial interventions may protect perinatal women from PTSD-like symptoms after a wildfire.

The Fort McMurray Mommy Baby Study: A Protocol to Reduce Maternal Stress Due to the 2016 Fort McMurray Wood Buffalo, Alberta, Canada Wildfire

Introduction: Data show that maternal stress triggered by exposure to a natural disaster before, during or just after pregnancy is associated with adverse pregnancy and newborn outcomes. In this paper, the first aim is to describe our efforts to test a simple, low-cost intervention to large numbers of women following a major natural disaster. The second aim is to outline the challenges faced and lessons learned during the execution of this natural disaster study. Methods: The setting was the May 2016 Fort McMurray Wood Buffalo wildfire in northern Alberta, Canada. Women who were pregnant or preconception at the time of the disaster were invited to participate via social media. This prospective cohort study included a randomized controlled trial to test the effectiveness of an expressive writing intervention on the levels of prenatal maternal stress and maternal, birth, and early childhood outcomes. At recruitment and at multiple timepoints postpartum, a battery of questionnaires was administered to evaluate objective and subjective stress exposure to the fire as well as maternal mental health, resilience and its contributing factors as well as infant developmental milestones. Qualitative content analysis of the expressive writing was conducted. Discussion: There is an increasing need to develop effective, wide-spread, rapid, and low-cost interventions to reduce prenatal maternal stress, increase resilience, and improve pregnancy outcomes following a natural disaster. Though analysis of data is ongoing, we highlight the strengths of this study which include strong community participation, rapid recruitment of eligible participants, low-cost intervention and data acquisition, and successful testing of the intervention. We acknowledge the challenges we encountered including the high rate of participant disqualifications or losses due to incomplete collection of online data; evacuation, dispersal, and inconsistent return to homes; and the high levels of stress accumulated post-disaster which led to inability to complete the study. Despite potential challenges, there remains a need for such research amid natural disasters.

Early Environmental Upheaval and the Risk for Schizophrenia

Why does prenatal exposure to wars, natural disasters, urbanicity, or winter increase the risk for schizophrenia? Research from the last two decades has provided rich insight about the underlying chains of causation at play during environmental upheaval, from conception to early infancy. In this review, we appraise the evidence linking schizophrenia spectrum disorder to prenatal maternal stress, obstetric complications, early infections, and maternal nutrition and other lifestyle factors. We discuss putative mechanisms, including the maternal stress system, perinatal hypoxia, and maternal-offspring immune activation. We propose that gene-environment interactions, timing during development, and sex differentiate the neuropsychiatric outcomes. Future research should pursue the translation of animal studies to humans and the longitudinal associations between early exposures, intermediate phenotypes, and psychiatric disorders. Finally, to paint a comprehensive model of risk and to harness targets for prevention, we argue that risk factors should be situated within the individual's personal ecosystem.

Positive cognitive appraisal "buffers" the long-term effect of peritraumatic distress on maternal anxiety: The Queensland Flood Study

BACKGROUND

Limited research has evaluated distinct aspects of disaster experience as predictors of affective symptoms. In this study, we examined the extent to which maternal depression and anxiety over time were predicted by (1) objective hardship from a flood during pregnancy, (2) peritraumatic distress and (3) cognitive appraisal of the flood's consequences.

METHODS

Data were drawn from the 2011 Queensland Flood Study, a prospective, longitudinal study of pregnancy (n = 183). Mothers' disaster experience was measured within 1 year after the flood. Their levels of depression, anxiety and stress were measured at 16 months, 30 months, 4 years and 6 years after childbirth. Linear mixed models were employed to evaluate symptom trajectories.

RESULTS

There were no time-dependent effects of disaster-related variables. Objective hardship did not predict outcomes. Peritraumatic distress significantly predicted depression and anxiety symptoms when cognitive appraisal was negative. Conversely, when cognitive appraisal was neutral or positive, the effect of peritraumatic distress was "buffered". For anxiety, but not depression, this interaction survived Bonferroni correction. Neutral/positive cognitive appraisal similarly moderated the effect of peritraumatic dissociation.

LIMITATIONS

The generalizability of our findings is limited by overall low levels of depression and anxiety, along with a predominantly Caucasian, higher socioeconomic status sample. Potential confounders such as pre-disaster anxiety were not controlled for.

CONCLUSION

In line with previous evidence, this study supports the predictive validity of peritraumatic distress for post-disaster depression and anxiety. Our findings suggest that cognitive appraisal could be a relevant target for interventions aimed at fostering maternal resilience.

Risk of cognitive impairment in children after maternal exposure to the 1998 Yangtze River flood during pregnancy: analysis of data from China's second National Sample Survey on Disability

BACKGROUND

More research is needed to understand the long-term effects of prenatal exposure to adverse events, such as floods and other natural disasters, on cognitive outcomes in childhood. We aimed to explore the risk of cognitive impairment in children following maternal exposure to the 1998 Yangtze River flood in China during pregnancy.

METHODS

For this study we obtained and analysed individual-level data from the second China National Sample Survey on Disability (CNSSD), which was done in 2006. We defined the flood period as June-August, 1998. The analytical sample comprised children from four birth cohorts, defined according to their month of birth: the post-partum exposed cohort (children born between June, 1997, and May, 1998), the prenatal exposed cohort (children born between June, 1998, and May, 1999), the preconception exposed cohort (children born between June 1999, and May, 2000), and the unexposed cohort (children born between June, 2000, and May, 2001). In the CNSSD, cognitive impairment was assessed and diagnosed by validated screening tools and procedures. Difference-in-difference models were used to examine variations in the effects of maternal flood exposure on cognitive impairment in childhood across the different birth cohorts and regions.

FINDINGS

108 175 children born between June, 1997, and May, 2001, and aged 4-8 years at the time of the survey, were included in our analysis. 1131 children had a cognitive impairment; the prevalence of cognitive impairment was 1·05% (95% CI 0·99-1·11). Maternal exposure to flood during pregnancy increased the risk of cognitive impairment among children (adjusted odds ratio [OR] 2·18 [95% CI 1·54-3·08]; p<0·0001). No significant sex-specific differences were observed, and the risk of cognitive impairment was especially high when maternal flood exposure occurred during the first trimester of pregnancy (adjusted OR 5·05 [95% CI 3·88-6·58]; p<0·0001). The risk of cognitive impairment also increased with longer durations of maternal flood exposure and with increasing severity of flooding; the risk was highest in the prenatal exposed cohort with 3 months of flood exposure in the most severely affected area (adjusted OR 5·56 [95% CI 1·58-19·54]; p=0·007).

INTERPRETATION

Prenatal flood exposure had a long-term negative effect on cognitive development of children. Greater maternal support and public health interventions during pregnancy and early life after a natural disaster are warranted to facilitate healthy cognitive development in later life.

FUNDING

National Social Science Foundation of China.

Value based maternal and newborn care requires alignment of adequate resources with high value activities

Background

Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies.

Discussion

Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, ‘from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all’.

Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are ‘the demands and beliefs of the acute sector’. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services.

Summary

To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

A cross-lagged panel analysis of children's sleep, attention, and mood in a prenatally stressed cohort: The QF2011 Queensland flood study

BACKGROUND

It is well recognized that childhood sleep, attention and mood problems increase risk for multiple adverse outcomes across the life-span; therefore, understanding factors, such as prenatal maternal stress, that underlie these types of childhood problems is critical for developing interventions that may optimize longer-term functioning. Our goal was to determine the association between disaster-related stress in pregnancy and young children's sleep, attention, and anxious/depressed symptoms.

METHODS

Soon after a major flood in Australia in 2011, we assessed various aspects of disaster-related prenatal maternal stress (PNMS) in women who had been pregnant at the time. Mothers rated several domains of their children's development with the Child Behavior Checklist (CBCL) at ages 2½ (n = 134) and 4 years (n = 118).

RESULTS

The primary finding was that more severe objective flood-related hardship in pregnancy predicted higher sleep problem scores at 2½ years, and that a negative maternal cognitive appraisal of the flood predicted lower attention problem scores at 2½ years. A cross-lagged panel analysis examined the association between children's sleep, attention, and anxious/depressed symptoms within and across ages. Results showed that these problems were likely to co-occur at each age, and that they were stable from 2½ to 4 years. Additionally, anxious/depressed scores at age 2½ predicted sleep problem scores at 4 years, all else being equal.

LIMITATIONS

Limitations of the study include a relatively small sample size and the children's outcome data relied on maternal report using the CBCL, rather than independent observation of the children's functioning, which may have introduced reporter bias.

CONCLUSIONS

These findings highlight the importance of early intervention for these childhood problems to optimize long-term mental health, particularly under conditions of prenatal stress.