Allison Shorten

Midwives and pregnant women talk about alcohol: what advice do we give and what do they receive?

BACKGROUND the Australian National Health and Medical Research Council (NHMRC) recently revised its guidelines for alcohol consumption during pregnancy and breast feeding, moving from a recommendation of minimising intake to one of abstinence. Women are potentially exposed to a variety of messages about alcohol and pregnancy, including from the media and social contacts, and are likely to see midwives as the source of expert advice in understanding these contradictory messages. OBJECTIVE to explore the advice that midwives believe they give to pregnant women about alcohol consumption, and the advice that pregnant women believe they receive; the knowledge and attitudes of both groups regarding alcohol consumption and the consistency with the NHMRC guidelines; and the receptivity and comfort of both groups in discussing alcohol consumption in the context of antenatal appointments. DESIGN individual semi-structured interviews with midwives and pregnant women. SETTING face-to-face interviews with midwives and telephone interviews with pregnant women were conducted in two regional areas of New South Wales in 2008-2009. PARTICIPANTS 12 midwives and 12 pregnant women. FINDINGS midwives and pregnant women consistently agreed that conversations about alcohol are generally limited to brief screening questions at the first visit, and the risks are not discussed or explained (except for high-risk women). KEY CONCLUSIONS both groups expressed comfort with the idea of discussing alcohol consumption, but lacked knowledge of the risk and recommendation, and it appears that this opportunity to provide women with information is under-utilised. IMPLICATIONS FOR PRACTICE there is a need to provide midwives with accurate information about the risks of alcohol consumption during pregnancy and effective communication tools to encourage them to discuss the risks and recommendations with their patients.

Maternal and neonatal effects of caesarean section

More accurate estimates of probabilities are needed to support informed childbirth choices

The Importance of Mode of Birth After Previous Cesarean: Success, Satisfaction, and Postnatal Health

INTRODUCTION The recent National Institutes of Health consensus conference on vaginal birth after cesarean (VBAC) recommended a focus on strategies that increase womens opportunities to make informed choices about VBAC. This study aimed to expand knowledge of womens experiences of planned VBAC by focusing on postnatal experiences of women who participated in an Australian birth-after-cesarean study. METHODS At 6 to 8 weeks after birth, 165 women who experienced childbirth after a previous cesarean rated satisfaction with their birth experiences using a 10-point visual analogue scale, reported on postnatal health problems, and indicated whether they would make the same birth choice again. RESULTS Significant differences were found in satisfaction scores by mode of birth. Mean scores out of a possible score of 10 ranged from 8.86 for spontaneous vaginal birth, 7.86 for elective repeat cesarean delivery, 6.71 for emergency cesarean delivery, to 6.15 for instrumental vaginal birth (F = 5.33; P = .002). Mean satisfaction scores for spontaneous vaginal birth and elective repeat cesarean delivery were statistically higher than for instrumental vaginal birth and emergency cesarean birth. Women who experienced instrumental vaginal birth and emergency cesarean birth also reported a higher number of postnatal health-related problems and were least likely to agree that they would make the same birth choice again. DISCUSSION Mode of birth was the most important determinant of postnatal satisfaction, postnatal health, and whether women felt they would make the same birth choice again. Clinicians, researchers, and policymakers should identify effective labor management practices that enhance womens opportunities to achieve spontaneous vaginal birth during planned VBAC.

The challenge of preconception counseling: Using reproductive life planning in primary care.

Purpose A case study is used  to explore barriers and challenges in the delivery of preconception care, and to highlight the future role of reproductive life planning in primary practice settings. Data sources Peer-reviewed  journal articles and clinical practice guidelines pertaining to preconception care. Conclusions Because of the high rate of unintended pregnancy, preconception care should be incorporated into routine primary care for women of reproductive age. Reproductive life plans are tools that help formalize contraceptive and preconception care for women across the life span. They may prove particularly useful for women with chronic diseases and for young, low-income, and minority women. Implications for practice With their emphasis on holistic care and patient education, nurse practitioners are well suited to incorporate elements of preconception care into the routine care they provide patients. Clinicians can modify reproductive life plans to fit the unique needs of an individual, patient population, or clinical practice.Purpose: A case study is used to explore barriers and challenges in the delivery of preconception care, and to highlight the future role of reproductive life planning in primary practice settings. Data sources: Peer‐reviewed journal articles and clinical practice guidelines pertaining to preconception care. Conclusions: Because of the high rate of unintended pregnancy, preconception care should be incorporated into routine primary care for women of reproductive age. Reproductive life plans are tools that help formalize contraceptive and preconception care for women across the life span. They may prove particularly useful for women with chronic diseases and for young, low‐income, and minority women. Implications for practice: With their emphasis on holistic care and patient education, nurse practitioners are well suited to incorporate elements of preconception care into the routine care they provide patients. Clinicians can modify reproductive life plans to fit the unique needs of an individual, patient population, or clinical practice.

Service evaluation, audit and research: what is the difference?

Knowing the difference between health service evaluation, audit and research can be tricky especially for the novice researcher. Put simply, nursing research involves finding the answers to questions about “what nurses should do to help patients,” audit examines “whether nurses are doing this , and if not, why not,”1 and service evaluation asks about “the effect of nursing care on patient experiences and outcomes .” In this paper, we aim to provide some tips to help guide you through the decision-making process as you begin to plan your evaluation, audit or research project. As a starting point box 1 provides key definitions for each type of project. ### Box 1 Definitions of service evaluation, audit and research ▸  What is service evaluation? Service evaluation seeks to assess how well a service is achieving its intended aims. It is undertaken to benefit the people using a particular healthcare service and is designed and conducted with the sole purpose of defining or judging the current service.2 The results of service evaluations are mostly used to generate information that can be used to inform local decision-making. ▸  What is (clinical) audit? The English Department of Health3 states …

Developing an Internet-Based Decision Aid for Women Choosing Between Vaginal Birth After Cesarean and Planned Repeat Cesarean.

INTRODUCTION In response to the call to develop strategies to engage women and providers in shared decision making, this article outlines a framework and process used to create an Internet-based decision aid about birth choices after previous cesarean. Recognizing the potential benefits of mobile health information technology, a paper-based decision aid was transformed into a secure, interactive Web site to meet the diverse needs of women and providers in this often challenging health care decision. METHODS An iterative and participatory research approach was used, engaging targeted users (pregnant women and pregnancy care providers) in the design and development process. RESULTS Women recommended that features and functions of the decision aid should include individualized information, trustworthy evidence, a secure and private site, quizzes to check knowledge, and a way to share values and preferences with their providers. Providers recommended individualized information for women, a process for women to share and document values and preferences with providers, and balanced, straightforward and complete information about the risks and benefits of each option. DISCUSSION There is great potential for direct linkage between Internet-based decision aids and the electronic medical record. Work is currently underway to integrate and evaluate the Internet-based decision aid within busy practice settings to support shared decision making. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

A Model of Adaptation of Overseas Nurses Exploring the Experiences of Japanese Nurses Working in Australia

Purpose: The purpose of the study was to investigate the experiences of Japanese nurses and their adaptation to their work environment in Australia. Using a qualitative research method and semistructured interviews, the study aimed to discover, describe, and analyze the experiences of 14 Japanese nurses participating in the study. Design: A qualitative study. Method: Fourteen Japanese registered nurses working in Australian hospitals participated in the study. Individual semistructured interviews were conducted from April to June in 2008. Thematic analysis was used to identify themes within the data. Results: Analysis of qualitative open-ended questions revealed the participants’ adaptation process. It consists of three themes or phases: seeking (S), acclimatizing (A), and settling (S), subsequently named the S.A.S. model. Discussion: The conceptual model of the adaptation processes of 14 Japanese nurses working in Australia includes the seeking, acclimatizing, and settling phases. Although these phases are not mutually exclusive and the process is not necessarily uniformly linear, all participants in this study passed through this S.A.S. model in order to adapt to their new environment. Implications for Practice: The S.A.S. model of adaptation helps to describe the experiences of Japanese overseas qualified nurses working in Australian hospitals. Future research is needed to examine whether this model can be applied to nurses from other countries and in other settings outside Australia.

What is meta-analysis?

When clinicians begin their search for the best available evidence to inform decision-making, they are usually directed to the top of the ‘evidence pyramid’ to find out whether a systematic review and meta-analysis have been conducted. The Cochrane Library1 is fast filling with systematic reviews and meta-analyses that aim to answer important clinical questions and provide the most reliable evidence to inform practice and research. So what is meta-analysis and how can it contribute to practice? Meta-analysis is a research process used to systematically synthesise or merge the findings of single, independent studies, using statistical methods to calculate an overall or ‘absolute’ effect.2 Meta-analysis does not simply pool data from smaller studies to achieve a larger sample size. Analysts use well recognised, systematic methods to account for differences in sample size, variability (heterogeneity) in study approach and findings (treatment effects) and test how sensitive their results are to their own systematic review protocol (study selection and statistical analysis).2 ,3 There is debate about the best practice for meta-analysis, however there are five common steps. ### Step 1: the research question A clinical research question is identified and a hypothesis proposed. The likely clinical significance is explained and the study design and analytical plan are justified. ### Step 2: systematic review A systematic review (SR) is specifically designed to address the research question and conducted …

Perineal outcomes in NSW public and private hospitals: Analysis recent trends

Women using private health insurance for pregnancy care may be unaware of the impact that this choice has in increasing their risk of experiencing a range of interventions during childbirth. This paper identifies recent trends in episiotomy rates and perineal outcomes for New South Wales (NSW) public and private hospitals between 1997 and 1999. Clear and consistent differences exist in birth outcomes in NSW private hospitals in respect to greater episiotomy use and poorer overall perineal outcomes, higher caesarean section rates and higher instrumental birth rates. Given the potential health impact for women who experience intervention during childbirth, identification of clinically unjustified practices is an important step towards ensuring that womens choices provide them with optimal childbirth outcomes regardless of their health insurance status.

Trends in birth choices after caesarean section in Japan: A national survey examining information and access to vaginal birth after caesarean

OBJECTIVES in the context of a rising caesarean section (CS) rate in Japan, the objectives of this study were; to investigate the national situation for womens birth options after primary CS; to explore characteristics of institutions accepting planned vaginal birth after caesarean (VBAC); to identify the timing and type of information given to women about their birth options by health professionals. DESIGN a national census study using a self-administered postal survey of nursing managers within obstetric departments in Japanese hospitals and clinics was conducted. Data were analyzed to explore characteristics of institutions accepting or not accepting VBAC and information given to women about planned VBAC and planned repeat CS. SETTING institutions included hospitals and clinics providing childbirth services throughout Japan. PARTICIPANTS nursing managers from hospitals (n=303) and clinics (n=196) completed surveys about their institutional policies and practices around birth after CS. FINDINGS only 154 (30.9%) of 499 institutions examined, accepted planned vaginal birth as an option for birth after CS. The success rate of VBAC was 77.0% in these institutions. Availability of transport services for institutional transfer and existence of a Maternal Fetal Intensive Care Unit (MFICU) were significantly associated with acceptance of VBAC (OR=5.39, p<0.001; OR=2.96, p=0.04). Information about options for birth method was mostly provided in the form of consent documents, and doctors were the sole provider of information about method of childbirth in 55.7% of institutions. Nursing managers described challenges in caring for women who strongly desire VBAC when women did not have access to information or if institutional policies conflicted with womens wishes. They recommended evidence-based information for women regarding birth choices after CS and recognised the necessity of emotional support for women faced with decision dilemmas. KEY CONCLUSIONS institutional policies and practices for birth after CS vary widely in Japan, with evidence of limited opportunities for women to make informed choices about planned VBAC. It was difficult for nurse managers to support women to choose VBAC when institutional policy conflicted with this choice and when women did not have consistent or balanced information. IMPLICATIONS FOR PRACTICE strategies are needed to support women as well as pregnancy care providers to support women to consider VBAC as a possible birth option after CS and to expand the use of shared decision making in pregnancy care settings in Japan.