A breastfeeding study in a rural population in South Australia

INTRODUCTION

The benefits of breastfeeding for mothers and babies are well recognised; however, challenges to its establishment and maintenance exist in rural locations.

METHOD

This study in a rural community aimed to: (1) collect rates of any breastfeeding at 6 weeks, 3 months and 6 months postpartum; and (2) seek women's postnatal breastfeeding needs and discern how they were met. Fifty-eight women, most of whom had planned to birth at one of two rural hospitals with fewer than 50 births a year were interviewed face-to-face or by telephone. Questions included whether they were still breastfeeding, reasons for stopping, and their breastfeeding support needs in hospital and after discharge on eight domains: establishment; attachment; engorgement; sore nipples; cracked nipples; ongoing support; supply and mastitis.

RESULTS

The number breastfeeding at 3 months (55%) compared poorly with South Australia (62%) or nationally (63%). Midwives met most of the needs of the women in hospital while, at home, midwives and GPs remained the main sources of support. At home, small numbers contacted the Australian Breastfeeding Association, child and youth health service nurse; a midwife employed by a pharmacist and family members such as mothers and mothers-in-law for support. Overall, 25% of women who had an identified need did not seek help. Of those who did, 36% had the need met well and 28% poorly. After discharge, 52 (90%) would have welcomed a visit from a community midwife had it been available. In the regional town, facilities to breastfeed and change babies' nappies were rated poor or non-existent.

CONCLUSION

Since this study, a part-time community midwife has been employed and a new project initiated that educates and assists older women volunteers to support and promote breastfeeding for isolated new mothers.

A survey of midwives who participated in a randomised trial of perineal massage in labour

A multi-centred randomised perineal massage in labour trial (PMLT) was conducted in which participating midwives randomised eligible women in the second stage of labour. A survey of these midwives was conducted after completion of the PMLT, but before results had been analysed and presented. The aim of the study was to seek from midwives, following the PMLT, their reasons why some eligible women were not randomly allocated to a group; why others did not receive care as allocated and the midwives' views about the massage, including whether significant trial results would influence their clinical practice. (This paper presents the results of this survey.)

Assisting women to establish breastfeeding: exploring midwives' practices

Breastfeeding is recognised by many mothers, families and health professionals to be important for the health and wellbeing of mothers and babies. Successful breastfeeding depends on the acquisition of basic skills, accurate information and practice, and is strongly influenced by the support provided following childbirth. Midwives' practices may therefore have the potential to influence breastfeeding outcomes. Correct positioning and attachment of the newborn at the breast is a crucial component of the successful establishment of breastfeeding. A literature review revealed that minimal research exists on the practices that midwives use when assisting women to initiate breastfeeding. A series of focus group interviews were therefore conducted to stimulate in-depth exploration of midwives' understanding and practices in the positioning and attachment of a newborn infant at the breast. Eighteen midwives, each of whom had worked at least 12 months in the postnatal environment of a large metropolitan hospital in Adelaide, participated in the focus group discussions. Using thematic analysis, the following broad themes emerged from discussions--education, problem-solving, support, midwives' views about breastfeeding and influences on midwives' practice. These themes identify the roles and practices that midwives take on when assisting women to establish breastfeeding following childbirth, and also raise awareness of influences on their practice.

Care of the perineum in the second stage of labour: a study of views and practices of Australian midwives

OBJECTIVES

to seek the views of midwives on the practices related to the perineum in the second stage of labour; to identify predictors of their practices and to identify their actual practices in the second stage of labour, prior to a randomised trial of second stage perineal massage.

PARTICIPANTS AND SETTING

independent midwives in South Australia and 194 midwives working in the delivery suites and birth centres of seven public hospitals in four states of Australia.

DESIGN

midwives were surveyed using a questionnaire which sought their views on, and practices relating to, second stage perineal massage, delivery of the head and reasons for cutting an episiotomy.

FINDINGS

one third of the respondents 'never' practised perineal massage in the second stage of labour, 43% were 'undecided' as to its value and 19% disagreed with the practice. Over half agreed that its use should be decided by the woman and her partner. When invited to select the five statements they most agreed with, and the five they most disagreed with, out of a possible 24, equal numbers (26%) were for and against the statement referring to such massage as helping to stretch the perineum and prevent tearing. More than half (55%) disagreed with the statement which predicted they would find the practice distasteful, while only 1.6% agreed with this statement. During delivery of the head, 71% of respondents attempted some form of flexion. There was 100% agreement that fetal distress almost always or frequently was an indication for cutting an episiotomy.

CONCLUSIONS

there is little evidence from randomised trials to support many of the second stage practices, and further research will clarify those which are most effective. This sample of midwives demonstrated considerable variation in their views on, and practices in, the second stage of labour. Although one-fifth disagreed with the practice of second stage perineal massage, and 40% agreed that the midwife should decide, more than half (57%) believed it was a matter of choice for the woman and her partner. All were supportive of episiotomy use for fetal distress.

Predicting postnatal depression among pregnant women

BACKGROUND

Depression after the birth of a baby is a common cause of maternal morbidity, and its prevalence in Australia is 10 to 15 percent at 6 to 9 months postpartum. This study assesses the prediction of postnatal depression at 6 weeks postpartum.

METHOD

Women at 24 weeks' gestation or less were invited to complete a Modified Antenatal Screening Questionnaire (MASQ) that identified women more vulnerable to becoming depressed after childbirth. Of these 249 women, 144 (58%) screened more vulnerable, and were randomly allocated to receive either a supportive intervention to reduce postnatal depression or to receive no intervention. At 6 weeks postpartum the women completed the Edinburgh Postnatal Depression Scale (EPDS) to assess their mood after the birth.

RESULTS

No difference occurred at 6 weeks postpartum between the MASQ vulnerable group (return rate 64/68) and the MASQ less vulnerable group (return rate 44/51) in the frequency of those who screened as potential candidates for major depression using the EPDS. For major depression the MASQ's sensitivity was 73 percent, specificity 43 percent, positive predictive value 17 percent, and negative predictive value 91 percent; for minor depression its sensitivity was 81, 48, 34, and 89 percent, respectively. The MASQ was able to predict minor depression. More women in the vulnerable group scored at increased risk of minor depression on the EPDS at 6 weeks postpartum.

CONCLUSION

Further studies are needed to extend this work and develop a screening test with higher specificity and greater positive predictive value.

Factors influencing the development of melatonin rhythmicity in humans

The emergence of melatonin rhythmicity was studied in 163 infants between 46-55 weeks postconception by monitoring the excretion of the urinary melatonin metabolite 6-sulfatoxymelatonin (aMT.6S). From this population, we examined the effects of gender, season, multiple birth, home birth, previous sudden infant death syndrome in the family, premature labor, spontaneous rupture of membranes, preeclampsia, intrauterine growth restriction, and nursery lighting on pineal rhythmicity. As previously reported, rhythmic excretion of aMT.6S appeared between 49-55 weeks postconception (9-15 weeks of age) in singleton babies born at term in the hospital. Full-term infants who had a sibling die of sudden infant death syndrome had a pattern of melatonin rhythm development no different from that of the control full-term infants. In contrast, full-term infants born at home and full-term twins born in the hospital had significantly lower aMT.6S excretion than hospital-born singleton infants at the same ages despite similar body weights (e.g. at 52 weeks postconception; 1.8 +/- 0.4, 1.1 +/- 0.3, and 3.6 +/ -0.5 nmol/day, respectively). In full-term infants, there was no difference in the development of melatonin rhythmicity between the sexes, with season or method of delivery (vaginal vs. caesarean). The premature infants were divided into 5 groups (babies born after premature labor, premature rupture of membranes, preeclampsia, intrauterine growth restriction, and fetal distress). All premature infants had a delay in the appearance of aMT.6S rhythms in the urine in relation to chronological age. When the infants were compared on the basis of weeks since conception, those infants born after spontaneous premature labor excreted amounts of aMT.6S no different from those of full-term singleton infants during the period of study. In contrast, the premature rupture of membranes, preeclampsia, and fetal distressed infants excreted 50% less aMT.6S, and intrauterine growth restricted infants excreted 67% less at the same postconceptional ages. These differences were due to reduced nocturnal excretion of the metabolite. In an attempt to accelerate the development of melatonin rhythmicity, premature labor and premature rupture of membranes infants were randomly assigned to be totally deprived of light (using phototherapy eye shields) or partially deprived of light by moving them to a dimly lit room each night for the last 3-8 weeks of their stay in the hospital nursery. Babies born after premature labor produced normal amounts of aMT.6S between 46-52 weeks postconception, and this pattern was not affected by the nocturnal light deprivation. Infants born after premature rupture of membranes and totally deprived of light at night had aMT.6S excretion rhythms at 52 weeks postconception no different from those of full-term hospital-born infants or premature labor infants, whereas those in infants placed in dim light were similar to those in untreated premature rupture of membranes infants. These results suggest that premature birth alone is not the sole cause of altered rhythm development; other factors, such as preeclampsia, growth restriction, and nursery lighting, play an important role. The consequences of the delayed appearance of melatonin in infants are not known, but deserve further study.

Evaluation of antenatal and postnatal support to overcome postnatal depression: a randomized, controlled trial

This randomized, controlled trial tested the hypothesis that women identified as more vulnerable to developing postnatal depression who attended two specific antenatal groups and one postnatal group have a reduced frequency of postnatal depression from 37 to 15 percent at 6 weeks, 12 weeks, and 6 months postpartum. A modified antenatal screening questionnaire was completed, and women identified as more vulnerable to postnatal depression were stratified by parity and randomly allocated to receive extra support groups or to a control group. The Edinburgh Postnatal Depression Scale (EPDS) was used to detect postnatal depression. Attendance at the support groups was low, 31 percent overall. At six weeks, in the intervention group, 8 (13%) of 64 women scored high (> 12) on the EPDS, compared with 11 (17%) controls. Similarly, at 12 weeks 7 (11%) of 63 versus 10 (15%) of 65 women scored higher than 12, and at 6 months, 9 (15%) of 60 versus 6 (10%) of 64 women scored higher than 12, indicating that the intervention did not reduce postnatal depression. It is possible that the method of applying the intervention, using groups separate from the standard antenatal classes, may have affected attendance. More research is required into ways of reaching and supporting women who may become depressed.

Women's views of their postnatal care by midwives at an Adelaide Women's Hospital

OBJECTIVE

to determine the characteristics of a sample of women giving birth in one hospital in South Australia and these women's perceptions of the usefulness of the advice and care that they were given during the puerperium

DESIGN

survey using questionnaires, incorporating Lipsett's (1984) questions, administered before the women left hospital and at six weeks postdelivery.

SETTING

one hospital in South Australia.

PARTICIPANTS

a sample of convenience of 235 women completed the hospital questionnaire and 222 (95%) returned the six weeks postpartum questionnaire.

FINDINGS

the women's ages ranged from 17-44 years, 86% were living in a stable relationship and 42% were primiparous. Most women (74%) made comments on the helpfulness of midwives. The midwife provided emotional support (57%), answered questions (32%) and gave information (30%). However, midwives' attitudes were perceived as insensitive (18%) and judgemental (9%). Midwives gave conflicting advice (10%) and 40% of the women made one or more comments about midwife unhelpfulness. Sixteen per cent of the women made no comment on the helpfulness of the midwife.

IMPLICATIONS FOR PRACTICE

contact with midwives in the early postnatal period is an ideal time for helpful advice and support to be given but midwives are not always perceived as fulfilling this part of their role. There is a need to address the issue of conflicting advice.

Postnatal depression: a South Australian prospective survey

The purpose of this study was to determine the prevalence of postnatal depression (PND) and to assess self-esteem in the early postnatal period and at 6 weeks postpartum and PND at 6 months postpartum. Women giving birth to term babies over a 6-month period, completed an Edinburgh postnatal depression scale (EPDS) and a Rosenberg self-esteem scale in hospital, at 6 weeks postpartum and an EPDS only at 6 months postpartum. A total of 235 women participated in the study of which 222 (95%) returned their questionnaire at 6 weeks postpartum and 192 (82%) at 6 months postpartum. Characteristics of the women and their pregnancy outcome are presented. The EPDS identified a depressed mood in 9% of women in hospital and at 6 weeks postpartum (95% CI 5.3%-12.8%). At 6 months this had increased to 10% (95% CI 7.8%-12.2%).

Development of melatonin production in infants and the impact of prematurity

The development of rhythmic 6-sulfatoxymelatonin excretion in urine was studied in healthy full-term and premature infants during the first 12 months of life. There was little evidence of rhythmic 6-sulfatoxymelatonin excretion before 9 to 12 weeks of age in full-term infants. Over this period, excretion increased five to six times compared to the excretion at 6 weeks (08 +/- 103 vs. 2973 +/- 438 pmol/24 h) with the major proportion of the hormone metabolite being excreted between 0200-1000 h. At 24 weeks of age, total 6-sulfatoxymelatonin excretion was 25% of adult levels. Premature infants (51 +/- 4 days premature) had a delay in the appearance of rhythmic 6-sulfatoxymelatonin of approximately 9 weeks. Even after correcting for gestational age or length of time at home, the premature infants were found to have a 2-3 week delay in the development of 6-sulfatoxymelatonin rhythmicity compared to full-term infants. These results provide evidence that neural centers responsible for rhythm generation and/or the pineal gland fail to accelerate their development after premature delivery. This may be due to the environment the infants are exposed to during their stay in hospital, particularly the pattern and intensity of lighting.