Beverley O’Brien

Gestational Diabetes: The Meaning of an At-Risk Pregnancy

Being diagnosed with gestational diabetes (GDM) is coupled with the implication that the woman and her fetus are at risk. In this study, the authors use a hermeneutic phenomenological approach to gain an in-depth understanding of GDM as pregnant women meaningfully experience it. They conducted conversational interviews with 12 women who were diagnosed with and being treated for diabetes in pregnancy. Data analysis involved a reflective process consistent with the guidelines of thematic analysis. Four themes identified as characteristic of the women’s pregnancy experience were Living a Controlled Pregnancy, Balancing, Being a Responsible Mother, and Being Transformed. The findings challenge health care professionals to discuss openly and reassess their present models of care for pregnant women and their families.

Cesarean and Vaginal Birth in Canadian Women: A Comparison of Experiences

BACKGROUND Many publications have examined the reasons behind the rising cesarean delivery rate around the world. Womens responses to the Maternity Experiences Survey of the Canadian Perinatal Surveillance System were examined to explore correlates of having a cesarean section on other experiences surrounding labor, birth, mother-infant contact, and breastfeeding. METHODS A randomly selected sample of 8,244 estimated eligible women stratified primarily by province and territory was drawn from the May 2006 Canadian Census. Completed responses were obtained from 6,421 women (78%). RESULTS Three-quarters of the women (73.7%) gave birth vaginally and 26.3 percent by cesarean section, including 13.5 percent with a planned cesarean and 12.8 percent with an unplanned cesarean. In addition to more interventions in labor, women who had a cesarean birth after attempting a vaginal birth had less mother-infant contact after birth and less optimal breastfeeding practices. CONCLUSION Findings from the Maternity Experiences Survey indicated that women who have cesarean births experience more interventions during labor and birth and have less optimal birthing and early parenting outcomes.

Use of Routine Interventions in Vaginal Labor and Birth: Findings from the Maternity Experiences Survey

BACKGROUND Intervention rates in maternity practices vary considerably across Canadian provinces and territories. The objective of this study was to describe the use of routine interventions and practices in labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Rates of interventions and practices are considered in the light of current evidence and both Canadian and international recommendations. METHODS A sample of 8,244 estimated eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census and stratified primarily by province and territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer-assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews averaged 45 minutes long and were completed when infants were between 5 and 10 months old (9-14 mo in the territories). Completed responses were obtained from 6,421 women (78%). RESULTS Women frequently reported electronic fetal monitoring, a health care practitioner starting or speeding up their labor (or trying to do so), epidural anesthesia, episiotomy, and a supine position for birth. Some women also reported pubic or perineal shaves, enemas, and pushing on the top of their abdomen. CONCLUSIONS Several practices and interventions were commonly reported in labor and birth in Canada, although evidence and Canadian and international guidelines recommend against their routine use. Practices not recommended for use at all, such as shaving, were also reported.

Comparison of Maternity Experiences of Canadian-Born and Recent and Non-Recent Immigrant Women: Findings From the Canadian Maternity Experiences Survey

OBJECTIVE To compare the maternity experiences of immigrant women (recent, ≤ 5 years in Canada; non-recent > 5 years) with those of Canadian-born women. METHODS This study was based on data from the Canadian Maternity Experiences Survey of the Public Health Agency of Canada. A stratified random sample of 6421 women was drawn from a sampling frame based on the 2006 Canadian Census of Population. Weighted proportions were calculated using survey sample weights. Multivariable logistic regression was used to estimate odds ratios comparing recent immigrant women with Canadian-born women and non-recent immigrant women with Canadian-born women, adjusting for education, income, parity, and maternal age. RESULTS The sample comprised 7.5% recent immigrants, 16.3% non-recent immigrants, and 76.2% Canadian-born women. Immigrant women reported experiencing less physical abuse and stress, and they were less likely to smoke or consume alcohol during pregnancy, than Canadian women; however, they were more likely to report high levels of postpartum depression symptoms and were less likely to have access to social support, to take folic acid before and during pregnancy, to rate their own and their infants health as optimal, and to place their infants on their backs for sleeping. Recent and non-recent immigrant women also had different experiences, suggesting that duration of residence in Canada plays a role in immigrant womens maternity experiences. CONCLUSION These findings can assist clinicians and policy-makers to understand the disparities that exist between immigrant and non-immigrant women in order to address the needs of immigrant women more effectively.

Bed Rest and Activity Restriction for Women at Risk for Preterm Birth: A Survey of Canadian Prenatal Care Providers

OBJECTIVE To explore the practices of Canadian obstetricians, family physicians, and midwives in recommending bed rest or activity restriction for women at risk for preterm birth (PTB) and to assess the decisional conflict experienced by care providers when they recommend these therapies. METHODS A self-administered mail survey of prenatal care providers was carried out using Dillmans Tailored Design Method. Analysis included descriptive statistics and analysis of variance. RESULTS The survey was distributed to 1441 potential participants; of these, 1172 were eligible participants, and 516 (44.2%) completed the survey. For women at risk of PTB, 60 of 170 obstetricians (35%), 88 of 206 family practitioners (42.7%), and 30 of 140 midwives (21.4%) recommended bed rest in hospital; 110 of 170 obstetricians (64.7%), 144 of 206 family practitioners (69.9%), and 73 of 140 midwives (52.1%) recommended bed rest at home. These recommendations occurred despite the response from about two thirds of each professional group that the effectiveness of bed rest was in the fair-to-poor range in helping to prevent PTB. The mean score on the Provider Decision Process Assessment Instrument, measuring decisional conflict for all care provider groups, was 30 (SD 7.4) (possible score range 12-60). There were no significant differences in decisional conflict scores among provider groups (F [2,347] = 2.24; P = 0.11). CONCLUSION Care providers have been discouraged from routinely recommending bed rest for women at risk of PTB because of potential adverse side effects. This study demonstrates that most Canadian prenatal care providers have not been persuaded to incorporate these recommendations into practice. Except for women with multiple gestation, there is inconsistent practice in recommending bed rest and activity restriction. Additionally, Canadian prenatal care providers have some decisional conflict about using this therapy. These results provide some of the first Canadian perspectives on the practice of prescribing therapeutic bed rest for PTB.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion

BackgroundPakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay.Methods/DesignData will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW’s in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan.DiscussionThe findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women’s marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.

Navigating maternity health care: a survey of the Canadian prairie newcomer experience

BackgroundImmigration to Canada has significantly increased in recent years, particularly in the Prairie Provinces. There is evidence that pregnant newcomer women often encounter challenges when attempting to navigate the health system. Our aim was to explore newcomer women’s experiences in Canada regarding pregnancy, delivery and postpartum care and to assess the degree to which Canada provides equitable access to pregnancy and delivery services.MethodsData were obtained from the Canadian Maternity Experiences Survey. Women (N = 6,241) participated in structured computer-assisted telephone interviews. Women from Alberta, Saskatchewan and Manitoba were included in this analysis. A total of 140 newcomers (arriving in Canada after 1996) and 1137 Canadian-born women met inclusion criteria.ResultsNewcomers were more likely to be university graduates, but had lower incomes than Canadian-born women. No differences were found in newcomer ability to access acceptable prenatal care, although fewer received information regarding emotional and physical changes during pregnancy. Rates of C-sections were higher for newcomers than Canadian-born women (36.1% vs. 24.7%, p = 0.02). Newcomers were also more likely to be placed in stirrups for birth and have an assisted birth.ConclusionAlthough newcomers residing in Prairie Provinces receive adequate maternity care, improvements are needed with respect to provision of information related to postpartum depression and informed choice around the need for C-sections.

An ethnographic study of communication challenges in maternity care for immigrant women in rural Alberta

BACKGROUND many immigrant and ethno-cultural groups in Canada face substantial barriers to accessing health care including language barriers. The negative consequences of miscommunication in health care settings are well documented although there has been little research on communication barriers facing immigrant women seeking maternity care in Canada. This study identified the nature of communication difficulties in maternity services from the perspectives of immigrant women, health care providers and social service providers in a small city in southern Alberta, Canada. METHODS a focused ethnography was undertaken incorporating interviews with 31 participants recruited using purposive and snowball sampling. A community liaison and several gatekeepers within the community assisted with recruitment and interpretation where needed (n=1). All interviews were recorded and audio files were transcribed verbatim by a professional transcriptionist. The data was analysed drawing upon principles expounded by Roper and Shapira (2000) for the analysis of ethnographic data, because of (1) the relevance to ethnographic data, (2) the clarity and transparency of the approach, (3) the systematic approach to analysis, and (4) the compatibility of the approach with computer-assisted qualitative analysis software programs such as Atlas.ti (ATLAS.ti Scientific Software Development GmbH, Germany). This process included (1) coding for descriptive labels, (2) sorting for patterns, (3) identification of outliers, (4) generation of themes, (5) generalising to generate constructs and theories, and (6) memoing including researcher reflections. FINDINGS four main themes were identified including verbal communication, unshared meaning, non-verbal communication to build relationships, and trauma, culture and open communication. Communication difficulties extended beyond matters of language competency to those encompassing non-verbal communication and its relation to shared meaning as well as the interplay of underlying pre-migration history and cultural factors which affect open communication, accessible health care and perhaps also maternal outcomes. CONCLUSION this study provided insights regarding maternity health care communication. Communication challenges may be experienced by all parties, yet the onus remains for health care providers and for those within health care management and professional bodies to ensure that providers are equipped with the skills necessary to facilitate culturally appropriate care.

Comparison of Costs and Associated Outcomes Between Women Choosing Newly Integrated Autonomous Midwifery Care and Matched Controls: A Pilot Study

OBJECTIVE In response to consumer demand and a critical shortage of Canadian maternity care providers, provinces have integrated or are in the process of integrating midwives into their health care systems. We compared the costs and outcomes of newly integrated, autonomous midwifery care with existing health care services in the province of Alberta. METHODS Alberta Health and Wellness cost data from (1) physician fee-for-service, (2) outpatient, and (3) inpatient records, as well as outcome data from vital statistics records, were compared between participants in a midwifery integration project and individually matched women who received standard perinatal care during the same time period. Records of births occurring within the same time frame were matched according to risk score, maternal age, parity, and postal code. RESULTS For women who chose midwifery care, an average saving of

Migration and maternity: insights of context, health policy, and research evidence on experiences and outcomes from a three country preliminary study across Germany, Canada, and the United Kingdom

1172 per course of care was realized without adversely affecting maternal or neonatal outcomes. Cost reductions are partially realized through provision of out-of-hospital health services. Women who chose midwifery care had more prenatal visits (P < 0.01) and fewer inductions of labour (P < 0.01); their babies had greater gestational ages (P < 0.05) and higher birth weights (P < 0.05) than controls. The sample size was insufficient to compare events associated with extremely high costs, or rare or catastrophic outcomes. CONCLUSION Regulated and publicly funded midwifery care appears to be an effective intervention for low-risk women who make this choice. When compared with existing care, autonomous care by newly integrated midwives does not increase health care costs.