February 26, 2021

Midwifery

One-on-one midwife care linked to lower risk of premature birth

by Leave a Comment

Women who have a midwife as their main carer throughout pregnancy and birth are around 23% less likely to have a premature baby than women whose care is shared between different obstetricians, GPs and midwives, a new systematic review published by The Cochrane Library has found.

Midwife-led continuity of care – in which a pregnant woman sees the same midwife during pregnancy and labour – is also associated with a lower risk of fetal loss before 24 weeks’ gestation and reduced likelihood of labour interventions such as episiotomies (a surgical cut) or use of forceps.

The latest Cochrane review, based on a systematic review of 13 trials involving 16,242 women, concluded that most women, unless they have significant risk factors, should have the option of midwife-led continuity of care.

“Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications,” the authors concluded.

“The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.”

Stunning outcome

Hannah Dahlen, Professor of Midwifery at University of Western Sydney, said the most significant finding was association between one-on-one midwife care and a significant reduction in the risk of preterm birth.

“Preterm birth is the major cause of early death and major disability for babies. So that’s a stunning outcome,” she said.

“If midwifery care was a tablet you could get at a pharmacy, the companies would be millionaires because everyone would take it.”

Professor Dahlen said that one-on-one care with a familiar midwife often reduces stress and anxiety for pregnant women.

“It’s the top level of scientific evidence that says women cared for by midwives they know have enormous advantages and no disadvantages. There are fewer babies dying, there are fewer things going wrong in labour.”

Some Australian hospitals offer midwifery-led continuity of care for pregnant women but demand for such programs often outstrips the number of places available.

Professor Dahlen said around 80% of pregnant New Zealand women have midwife led continuity of care but in Australia the figure is thought to be between 3 – 5%.

Cost effective

Sally Tracy, Professor in Midwifery at the University of Sydney, and conjoint Professor, School of Women’s and Children’s Health, Faculty of Medicine, UNSW, Midwifery and Women’s Health Research Unit, Royal Hospital for Women, said there was a perception that one-on-one midwife led care of pregnant women cost the health system more.

“But in fact, by the end of it, it costs less because of an accumulation of little things: less pain relief, fewer inductions, and women don’t stay as long in hospital,” she said.

Alec Welsh, Professor and Head of Maternal Fetal Medicine at the University of New South Wales and director of the Australian Centre for Perinatal Science said “you do see good continuity of care in private obstetrician practice as well.”

“But certainly the midwife-led models are associated with decreases in use of epidurals and decreased rates of intervention,” he said.

Hospitals and area health services should not view one-on-one midwife care as an expensive, boutique service and pregnant women should be made aware of the benefits of such schemes, he said.

“We need to get education out there that paying a lot of money for care doesn’t necessarily mean you will get the outcome you want.”

Andrew Bisits, Associate Professor (Conjoint), School of Women’s and Children’s Health at University of New South Wales and Medical Co-director of Maternity at the Royal Hospital for Women, Randwick, said that “at a policy level, more should be done to set up systems of care like this.”

“They are as safe as standard models of care and lead to benefits in the right direction and probably even more than this review even suggests,” he said.The Conversation

Sunanda Creagh, Editor, The Conversation

This article is republished from The Conversation under a Creative Commons license. Read the original article.

‘Like a piranha’: how midwives’ descriptions of breastfeeding affect women’s attitudes

by Leave a Comment

The World Health Organisation (WHO) promotes exclusive breastfeeding as the optimal way to feed infants. Most Australian babies – 96% – start out breastfeeding. But this figure drops to 61% exclusive breastfeeding at one month, 39% at three months and a very low 15% at five months.

The reasons women stop breastfeeding are widespread. They include pain and discomfort during early establishment, lack of support, fear the baby is not getting enough milk, plans to return to work, and worry about the baby’s enjoyment or fulfilment.

A woman’s confidence with breastfeeding can be impacted by her baby’s behaviour and the perceived quality and quantity of milk. Mothers often look to health professionals in the first few days after birth for help in making these assessments.

But a study my colleagues and I conducted in New South Wales found that the sometimes negative language that health professionals use, when describing normal behaviour while feeding, is far from helpful.

If health professionals’ interpretations of baby’s behaviours are negative, a woman may question whether breastfeeding is meeting her baby’s needs. The language used to describe the baby matters. Women who are not enjoying breastfeeding, or think their baby is not enjoying breastfeeding, are more likely to wean early.

Blaming the baby

Published in the journal Maternal and Child Nutrition, our research observed the breastfeeding interactions between 77 women and 36 midwives or lactation consultants at two New South Wales hospitals in the first week after the women gave birth. We also interviewed some of the midwives and the women separately.

At times health professionals attempted to shift blame for breastfeeding difficulties away from the mother. But in so doing they inadvertently placed blame onto the baby.

Midwives used terms such as “impatient” and “lazy” to describe the infant. Babies were deemed impatient, for example, if they were crying at the breast and not sucking. This was attributed to inheriting an “impatient personality”, demonstrated when the milk was not flowing fast enough for them at their first sucking efforts.

Some babies were considered “lazy” if they were not sucking for long enough or not acquiring sufficient breastmilk at each breastfeed.

In the first week after birth, health professionals took on the role of “infant interpreter” and offered what they thought the baby was “thinking”. The implication was that newborn babies had the capacity to think, make decisions and choose whether to cooperate with breastfeeding or not.

There was a definite impression that the baby had a “job” to do during breastfeeding. In this setting, a baby who “cooperated” with breastfeeding, and performed their “job” properly, was labelled “good”, “clever” and “smart”. Yet if the staff member felt the baby had “decided” not to “cooperate”, they used negative language.

Babies who were unsettled and “uncooperative” were described as being “cross”, “cranky” and “angry” during breastfeeding because the milk was not flowing fast enough for them. Babies were described as “complaining”, having “temper tantrums”, getting themselves into a “tizz” or using their mother as a “dummy”.

These kinds of repeated negative references to personality and unfavourable interpretations of baby behaviour ultimately influenced how some women perceived their babies.

The following quote demonstrates how the words health professionals use can become embedded in a woman’s own language. While this woman was in hospital, she told the midwife that she had sore nipples. The midwife replied:

Your nipples are a bit tender because you’re not used to having this little piranha hanging off them every five minutes.

Six weeks later, I interviewed the same woman at home and asked her to describe her early breastfeeding experience. She replied:

With the latching on and that, she’s a bit like a piranha. She grabs straight on…

Comparing the newborn baby to a harmful creature with a voracious appetite could have significant implications for the mother-baby breastfeeding relationship.

Mother and baby are both learning

We found that more positive language and interpretations of baby behaviour during breastfeeding emerged when health professionals viewed the mother and baby as two participants in a reciprocal relationship.

In these interactions, the baby was seen as an instinctual being who was learning how to breastfeed, and so was the mother.

The language that emerged normalised baby behaviours and reflected more positive interpretations. It also facilitated the mother “tuning in” to the needs of her baby.

At times when women themselves used negative language to describe their babies, the midwives focused on the relationship and encouraged a different interpretation. In one example, a mother interpreted her baby as “a stubborn little bugger” who “doesn’t make decisions real quick”.

The midwife shifted the focus to a more positive reading of the baby: “he just may not be quite ready yet” and “just do some skin-to-skin with him”.

When it comes to supporting women to breastfeed, language is very important. It can positively, or negatively, influence the developing relationship between mother and baby. Language should aim to enhance, rather than undermine, the mother-baby relationship and should facilitate the mother “tuning in” to her baby by identifying normal newborn behaviours.The Conversation

Elaine Burns, Lecturer in Midwifery, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Tokophobia is an extreme fear of childbirth. Here’s how to recognise and treat it

by Leave a Comment

Many pregnant women worry about birth. Some, however, suffer from a much more serious condition called tokophobia: a severe and unreasoning dread of childbirth, which is sometimes accompanied by a disgust of pregnancy.

At its most extreme, tokophobia can lead to:

  • an obsessive use of contraception to prevent pregnancy
  • termination of pregnancy
  • not attending maternity care appointments
  • post-traumatic stress disorder and/or other mental health disorders and mother-baby bonding difficulties.

Tokophobia comes in two forms: primary (in women who have not had a baby before) and secondary (women who have previously had a baby). Women with tokophobia in a previous pregnancy are more likely to have it in a subsequent pregnancy, resulting in a potential cycle of anxiety and depression.

Our new paper, published in the Journal of Reproductive and Infant Psychology, reflects on a recent meeting of researchers and clinicians about what’s missing from the way we identify and treat tokophobia.

Hard to define, hard to screen for

It’s hard to say how many women are affected by tokophobia; it’s been defined and measured using different questionnaires. One research paper estimated the prevalence of tokophobia at 14% of pregnant women worldwide.

Screening for tokophobia is not common practice around the world. Screening questionnaires sometimes ask the woman questions about her mood, whether she has fears for herself or her baby, about feeling so afraid of childbirth she’s considered terminating the pregnancy, or feeling fear so overwhelming it interferes with eating, work or sleep.

In other words, tokophobia goes beyond normal childbirth concerns and worries, and becomes an intense and irrational fear of pregnancy and/or labour.

It’s important women with this condition are identified as soon as possible but that often only happens when they seek specialised professional help. This can sometimes (but not always) take the form of a request for a termination of pregnancy or caesarean section.

Treatment options

Treatment for tokophobia remains patchy but should be determined based on factors such as the woman’s level of fear, stage of pregnancy and her individual wishes.

Early conversations about fear of childbirth — and understanding exactly what those fears are — may reduce negative impact and prevent anxiety.

For women with birth trauma (and potential secondary tokophobia), helping them prepare for uncertainty and building trust in themselves and their caregivers can result in a future positive experience.

Approaches that may help include:

  • additional midwifery support to discuss the birth, with continuity of care, which is where the same midwife and/or midwifery care team sees the woman throughout pregnancy and labour
  • involvement of the obstetrician in decision-making around birth
  • extra education about childbirth
  • the involvement of the birth partner,
  • supported visits to the delivery suite, and
  • the development of a supportive birth plan.

Pathways of care

The way childbirth is often depicted in the media may play a role in setting birth up in women’s minds as a negative experience. But it’s important women share birth stories – the good and the bad. Like-minded peer support mechanisms, including parenting forums, which can be really helpful for some women.

During pregnancy, women should be encouraged to share their fears with their maternity care provider and ask questions.

Our understanding of fear of childbirth has undoubtedly increased, and some pioneering “pathways of care” for women with tokophobia already exist.

But there is much work left to do if we are to understand and identify when standard worries deviate from expected levels to problematic levels.

We owe it to women and babies everywhere to find better ways to support women with tokophobia and maximise their chances of a positive birth experience.

Julie Jomeen, Professor of Midwifery and Dean in the Faculty of Health Sciences, Southern Cross University; Catriona Jones, Senior Research Fellow in Maternal and Reproductive Health, University of Hull; Claire Marshall, National Institute for Health Research Fellow, University of Hull, and Colin Martin, Adjunct professor, Southern Cross University

 

Blacktown Hospital fails to fix maternity crisis

by Leave a Comment

UPDATE: Since publishing, Blacktown Hospital has finally started advertising for the 15 FTE midwifery vacancies.

Frustrated by Blacktown Hospital management’s delays in following through on its commitments, the NSW Nurses and Midwives’ Association filed a dispute with the NSW Industrial Relations Commission last night.

The NSWNMA has been seeking genuine consultation to address the crisis in the maternity ward and for management to advertise the additional 15 full-time equivalent midwifery roles as they committed to do.

NSW Health Minister, Brad Hazzard, took steps to address the crisis by launching a thorough review in November. But in a meeting last week, Blacktown Hospital management could not provide a report to NSWNMA midwife representatives about the review and are acting as if the midwifery and obstetric issues are unrelated.

NSWNMA General Secretary, Brett Holmes, said Blacktown Hospital management is failing in its duty of care to staff and the community.

“The NSWNMA wants to participate in meaningful consultation to resolve the crisis,” Mr Holmes said. “But if Blacktown Hospital management won’t carry out its promise of more staff, the unreasonable workloads continue as does the threat to safe patient care.

“When Western Sydney LHD offered to add 15 extra midwives to the roster, we welcomed the move as a step in the right direction. Despite our concerns it will not be enough to address the very high workloads our members currently face.

“The LHD committed to advertising the roles in the week beginning November 30. It’s almost Christmas and still they have not placed an ad for the additional positions.

“Now we are hearing of delays to promised reviews, positions not being backfilled, and excessive overtime.

“Our members at Blacktown Hospital know how critical this situation is and their actions have proved that.

“In order to protect patient safety and in fear that their professional registrations are at risk, nurses and midwives have taken all reasonable steps possible.

“It’s time the Minister intervened again to ensure that this crisis is dealt with and resolved quickly. It shouldn’t be up to midwives to go to the courts to hold their management to account.

“Nurses and midwives at Blacktown deserve better and the Blacktown community deserves better.”

Dire situation forces Blacktown midwives to speak out

by 4 Comments

Traumatised and fatigued midwives at Blacktown Hospital are in desperate need of relief from unsafe staffing levels, which are putting patient safety and their professional registration at risk.

Following multiple infant fatalities over the past 18 months and ongoing staffing concerns, the midwives have given Western Sydney Local Health District 48 hours to address their concerns.

NSW Nurses and Midwives’ Association (NSWNMA) General Secretary, Brett Holmes, said Health Minister Brad Hazzard needs to urgently intervene in the matter.

“The situation is dire and many of these midwives no longer feel supported, despite repeatedly raising their concerns with hospital management,” said Mr Holmes.

“Since 2015, births at Blacktown Hospital have increased 52%, while staffing has only risen 11%.

“Year on year, the number of babies delivered at the hospital has continued to grow, with around 4,100 projected births this year.

“Currently, they’re averaging 11.5 births every 24 hours at Blacktown, with often only seven midwives rostered per shift. Meanwhile, at Westmead Hospital, midwives are assisting with an average 13.7 deliveries in 24 hours, yet they have ten midwives rostered per shift.

“For the past two years, our members at Blacktown Hospital have been battling short staffing and workloads issues which were only exacerbated after they relocated to a new, larger birthing unit as part of the hospital’s redevelopment.

“Due to obstetrician shortages, midwives are being trained to take on more roles, increasing their workloads each shift. On a regular basis, they’re also prevented from leaving work early if they miss meal breaks.

“Midwives are often being rostered for multiple day and night shifts of up to 64 hours over seven days, despite 56 hours being the maximum.

“Not only are they burning out with fatigue, many of the midwives have been traumatised by tragic deaths and believe the staffing issue has become untenable, putting their professional registrations at risk.”

Mr Holmes said the conditions were unsafe for midwives and patients, increasing the risk of further tragic outcomes.

One midwife described how many of them were struggling with the lack of support: “But most of us stay because we love what we do. We are passionate about our women and their babies. We are dedicated to them and their needs.”

Members of the NSWNMA’s Blacktown Hospital Branch are seeking urgent additional staffing while the Local Health District carries out a review of BirthRate Plus, the model used to determine staffing levels across maternity services.

They’re also requesting an immediate review of the hospital’s maternity services and calling for all existing vacancies to be filled.

Midwife elected to NZ Parliament in Labour Landslide 

by Leave a Comment

A midwifery lecturer has been elected for Labour in a safe conservative seat following Jacinda Ardern’s landslide victory in New Zealand.  

Sarah Pallett has been elected to the Christchurch-based seat of Ilam, defeating National Party deputy leader Gerry Brownlee in a surprise victory. 

Pallett was a midwifery and union activist at Ara Institute of Canterbury prior to her election. She had also worked as a rural midwife and at the Christchurch Women’s Hospital for ten years. 

Brownlee had held the seat since 1996, and entered the race with a 25% advantage over his Labour counterpart from the 2017 election.  

In finding out the result, Pallett said she was “so excited [and] absolutely blown away”.  

“I think it shows that Ilam was ready for a new MP,” she said.  

“Working in healthcare, I am uniquely placed to understand the opportunities and challenges in the area”.