ASK a Midwife: A Qualitative Study Protocol

Midwife-led institutions, also called free-standing birth centres, offer birth assistance to women at low risk for complications. Free-standing birth centres, because they are the institutions that provide low intervention birth assistance, also present the possibility to conduct research on the skills and knowledge that are necessary to provide safe care for women who are at low risk for complications desiring an out-of-hospital birth. The aim of this study is to reveal the skills and knowledge necessary to provide care at low intervention births in free-standing birth centres in Germany for midwives post-certification. The theoretical and methodological standpoint of this study is hermeneutic phenomenology. In-depth qualitative methods will be used that are particularly sensitive to the research participants and their social context and allow for complexity, detail and context. The research sites are free-standing birth centres in Germany. Three strands of data will be collected. Each birth centre has its own quality management handbook. From this handbook, the chapter concerning the induction of new midwives will be analysed. Small focus groups will be held in ten birth centres throughout Germany; and data will be collected from 10 to 20 midwives during their induction period at the birth centre. The data collection methods will be open-ended interviews, data capture, journaling and non-participant observation with the new midwives. In-depth data analysis will reveal midwives’ experiences of skill acquisition in free-standing birth centres. The findings will be used to produce key recommendations for training midwives to work in birth centres.

Vaccination Attitude and Communication in Early Settings: An Exploratory Study

Background: This study assesses attitudes towards vaccination in mothers of new-born babies and explores its association with different exposures to communication. Methods: Data were collected through questionnaires administered by means of interviews. Results: Data highlighted that 20% of mothers showed an orientation towards vaccine hesitancy. As for the reasons behind the attitude to vaccine hesitancy, data showed that concern is a common feature. As for the different exposures to communication, 49% of mothers did not remember having received or looked for any information about vaccination during pregnancy and post-partum; 25% stated they received information from several healthcare and non-healthcare sources; 26% declared having received or looked for information by means of healthcare and non-healthcare sources, as well as having taken part in a specific meeting during antenatal classes or at birth centres. The attitude towards vaccine hesitancy tends to reduce as exposure to different communication increases. Conclusions: This study supports the hypothesis that participation in interactive meetings in small groups focused on vaccination during the prenatal course or at the birth point may act as an enabling factor contributing to a decrease in the tendency to experience vaccine hesitation.

Potential of standard perinatal data for measuring maternal integrity in childbirth

Background Measuring the phenomenon of violation of maternal integrity in childbirth (e.g. obstetric violence) relies in part on the completeness of maternity care providers' data. The population coverage and linkage possibilities that they provide make for a great untapped potential. Although violation of integrity is a complex phenomenon best measured with dedicated instruments, standard data provide details about the birth and care received. Relevant variables include justifications of medical procedures (e.g. episiotomy) and characteristics of the birth process (e.g. length of labour). Demographic variables can be used for intersectional analyses to track potential discrimination -a dimension of violation of integrity in childbirth. Methods Using a baseline questionnaire and perinatal data obtained from hospitals, birth centres and midwifes in the BaBi study (Germany), we compared the completeness of integrity-relevant variables across providers and depending on the demographic and clinical characteristics of the women. We investigated potential for analysis from an intersectional perspective. Results Our analyses included 908 births, of which 32 outside hospital. There were 634 vaginal birth vs. 274 caesarean sections. We found poor reporting on demographic variables, in particular with regard to the 'region of origin' variable (correct origin recorded for half of the migrants). There was better reporting by midwives than by hospitals for “soft indicators”, such as the position of the women during birth (100% vs. 87.6%). Conclusions Putting more emphasis on completeness of standardised data could increase their potential for research. Healthcare setting, organisational culture and working conditions might determine what is judged important in terms of reporting; therefore, targeted education may improve this process. Next, we will interview care providers to understand data collection constraints and priorities and potential reporting bias in real-life settings.

How can consultant-led childbirth care at time of delivery be maximised? A modelling study

ObjectiveThe Royal College of Obstetricians and Gynaecologists has advised that consolidation of birth centres, where reasonable, into birth centres of at least 6000 admissions per year should allow constant consultant presence. Currently, only 17% of mothers attend such birth centres. The objective of this work was to examine the feasibility of consolidation of birth centres, from the perspectives of birth centre size and travel times for mothers.DesignComputer-based optimisation.SettingHospital-based births.Population or sample1.91 million admissions in 2014–2016.MethodsA multiple-objective genetic algorithm.Main outcome measuresTravel time for mothers and size of birth centres.ResultsCurrently, with 161 birth centres, 17% of women attend a birth centre with at least 6000 admissions per year. We estimate that 95% of women have a travel time of 30 min or less. An example scenario, with 100 birth centres, could provide 75% of care in birth centres with at least 6000 admissions per year, with 95% of women travelling 35 min or less to their closest birth centre. Planning at local level leads to reduced ability to meet admission and travel time targets.ConclusionsWhile it seems unrealistic to have all births in birth centres with at least 6000 admissions per year, it appears realistic to increase the percentage of mothers attending this type of birth centre from 17% to about 75% while maintaining reasonable travel times. Planning at a local level leads to suboptimal solutions.

Caesarean Delivery Rates in Birth Centres: confrontation using Robson Classification

Background A caesarean section (CS) is a life-saving procedure, reducing perinatal mortality and morbidity, over last decades CS rates are increasing. In 2015 the Robson classification (RC) was introduced by WHO as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities and between them. The aim of this cross-sectional study was to identify the most numerous groups according to RC. Methods All women, who delivered by CS from January 2015 to June 2017 in two hospitals in the province of Siena (Italy): I level Birth Centre of Grosseto (GR) and II level Birth Centre of Siena (SI) were included. Age, type of hospital and group based on RC were extracted from Medical Register. The RC divides women into 10 groups based on 5 basic obstetric characteristics (parity, number of foetuses, previous CS, onset of labour, gestational age, foetus presentation). The percentages of the group’s contribution to the overall CS rate were calculated and confronted for two birth centres. All analysis was performed with Stata. Results A total of 2115 women was analysed, 50.5% from SI. Average age was 34.3±5.7; significantly higher for SI (34.7±5.6vs33.9±5.8). Most contributing groups were group V: multiparous, singleton, cephalic, term, with previous CS (24.2%), group II: nulliparous, singleton, cephalic, term, induced labour or CS (24%), group I: nulliparous, singleton, cephalic, term, spontaneous labour (11.45%), group VIII: multiple pregnancy (10.7%) and group X: singleton, cephalic, pre-term (10.4%). Differences for type of birth centre were observed for groups I, II, V and VIII: I and VIII were more numerous in SI, II and V in GR (chi2; p < 0.05). Conclusions The most numerous groups were I, II e V, concordant with literature. Reduction of CS rates in group V could be obtained through lowering of primary CS rates and by promotion of Vaginal Birth After CS. Healthcare professionals could help to reduce labour-related anxiety and elective CS rates. Key messages The most contributing groups to overall caesarean section rates were groups I, II e V, as reported in literature. Reduction of CS rates could be obtained through lowering rates of primary CS, but also by promotion of Vaginal Birth After CS.

Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study

ObjectiveTo compare perinatal and maternal outcomes for Australian women with uncomplicated pregnancies according to planned place of birth, that is, in hospital labour wards, birth centres or at home.DesignA population-based retrospective design, linking and analysing routinely collected electronic data. Analysis comprised χ2tests and binary logistic regression for categorical data, yielding adjusted ORs. Continuous data were analysed using analysis of variance.SettingAll eight Australian states and territories.ParticipantsWomen with uncomplicated pregnancies who gave birth between 2000 and 2012 to a singleton baby in cephalic presentation at between 37 and 41 completed weeks’ gestation. Of the 1 251 420 births, 1 171 703 (93.6%) were planned in hospital labour wards, 71 505 (5.7%) in birth centres and 8212 (0.7%) at home.Main outcome measuresMode of birth, normal labour and birth, interventions and procedures during labour and birth, maternal complications, admission to special care/high dependency or intensive care units (mother or infant) and perinatal mortality (intrapartum stillbirth and neonatal death).ResultsCompared with planned hospital births, the odds of normal labour and birth were over twice as high in planned birth centre births (adjusted OR (AOR) 2.72; 99% CI 2.63 to 2.81) and nearly six times as high in planned home births (AOR 5.91; 99% CI 5.15 to 6.78). There were no statistically significant differences in the proportion of intrapartum stillbirths, early or late neonatal deaths between the three planned places of birth.ConclusionsThis is the first Australia-wide study to examine outcomes by planned place of birth. For healthy women in Australia having an uncomplicated pregnancy, planned births in birth centres or at home are associated with positive maternal outcomes although the number of homebirths was small overall. There were no significant differences in the perinatal mortality rate, although the absolute numbers of deaths were very small and therefore firm conclusions cannot be drawn about perinatal mortality outcomes.

First time mothers’ expectations and experiences of postnatal care in England: a longitudinal qualitative descriptive study

Background: Effective postnatal care can support a safe and confident transition to parenthood, but it is the aspect of maternity care with which women in England are least satisfied. Little is known about first time mothers’ expectations of postnatal care in hospitals, in birth centres and in the community, or how these expectations relate to their subsequent experiences and appraisal of care.Methods: A longitudinal qualitative descriptive study, based on semi-structured, in-depth interviews with first time mothers in England. Each mother took part in two interviews: the first in her third trimester of pregnancy, and the second when her baby was 2-3 months old. Interview transcripts were analysed using trajectory analysis to identify thematic patterns in the relationships between postnatal care expectations, needs, experiences and confidence. Individual cases were chosen to illustrate each trajectory and the variation within trajectories.Results: 32 women took part. Expectations of postnatal care did not shape their appraisal of care as actually experienced. Instead the main influence on satisfaction with care and self-described parental confidence was the extent to which their actual postnatal needs for support were met. Five trajectories were identified: (1) ‘Low needs, low support, confident’, (2) ‘High needs, high support, confident’, (3) ‘High needs, low support, not confident’, (4) ‘High needs, high support, additional risk factors, not confident’, (5) ‘High needs, low support, additional protective factors, confident’.Conclusions: Longitudinal qualitative research using trajectory analysis is a useful and feasible method of exploring expectations and subsequent experiences in the perinatal period. First time mothers’ satisfaction with postnatal care and their confidence as new mothers were primarily influenced not by the extent to which their expectations were met, but the varied extent to which their postnatal needs were met. Rapid and responsive assessment of needs both antenatally and postnatally, and appropriate adjustment of care, is key in supporting women effectively at this time. Providing tailored information on postnatal care, self-care and transition to parenthood during pregnancy may facilitate improvements in women’s experiences of care after birth in the hospital and community.